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Taming or teaching the tiger? Myths and management of childhood aggression
How to deal with aggression delivered by a child’s peers is a common concern and social dilemma for both parents and children. How does a child ward off aggressive peers without getting hurt or in trouble while also not looking weak or whiny? What can parents do to stop their child from being hurt or frightened but also not humiliate them or interfere with their learning important life skills by being over protective?
Children do not want to fight, but they do want to be treated fairly. Frustration, with its associated feelings of anger, is the most common reason for aggression. Being a child is certainly full of its frustrations because, while autonomy and desires are increasing, opportunities expand at a slower rate, particularly for children with developmental weaknesses or economic disadvantage. Fear and a lack of coping skills are other major reasons for resorting to aggressive responses.
Physical bullying affects 21% of students in grades 3-12 and is a risk factor for aggression at all ages. A full one-third of 9th-12th graders report having been in a physical fight in the last year. In grade school age and adolescence, factors known to be associated with peer aggression include the humiliation of school failure, substance use, and anger from experiencing parental or sibling aggression.
One would think a universal goal of parents would be to raise their children to get along with others without fighting. Unfortunately, some parents actually espouse childrearing methods that directly or indirectly make fighting more likely.
Essentially all toddlers and preschoolers can be aggressive at times to get things they want (instrumental) or when angry in the beginning of their second year of life; this peaks in the third year and typically declines after age 3 years. But for some 10% of children, aggression remains high. What parent and child factors set children up for such persistent aggression?
Parents have many reasons for how they raise their children, but some myths about parenting that persist promote aggression.
“My child will love me more if I am more permissive.”
Infants and toddlers develop self-regulation skills better when it is gradually expected of them with encouragement and support from their parents. Parents may feel that they are showing love to their toddler by having a “relaxed” home with few limits and no specific bedtime or rules. These parents also may “rescue” their child from frustrating situations by giving in to their demands or removing them from even mildly stressful situations.
These strategies can interfere with the progressive development of frustration tolerance, a key life skill. A lack of routines, inadequate sleep or food, overstimulation by noise, frightening experiences (including fighting in the home or neighborhood), or violent media exposure sets toddlers up to be out of control and thereby increases dysregulation. In addition, the dysregulated child may then act up, which can invoke punishment from that same parent.
Frustrating toddlers with inconsistent expectations and arbitrary punishment, a common result of low structure, makes the child feel insecure and leads to aggression. Instead, children need small doses of frustration appropriate to their age and encouragement from a supportive adult to problem solve. You can praise (or model), cheering on a child with words such as “Are you stuck? You can do it! Try again,” instead of instantly solving problems for them.
“Spare the rod and spoil the child.”
Parents may feel that they are promoting obedience when they use corporal punishment, thinking this will keep the child out of trouble in society. Instead, corporal punishment is associated with increased aggression toward peers, as well as defiance toward parents. These effects are especially strong when mothers are distant emotionally. As pediatricians, we can educate people on the importance of warm parenting, redirection instead of punishment for younger children, and using small, logical consequences or time out when needed for aggression.
“Just ignore bullies.”
It is a rare child who can follow the command to “ignore” a bully without turning red or getting tears in his or her eyes – making them appealing targets. We can coach parents and kids how to disarm bullies by standing tall, putting hands on hips, making eye contact, and asking the peer a question such as “I do not understand what you’re trying to accomplish.” Learning martial arts also teaches children that they are powerful (but not to fight outside the class) so they can present themselves in this way. Programs that encourage children to get together to confront bullies supported by a school administration that uses comprehensive assessment and habilitation strategies for aggressive students are most effective in reducing aggression in schools. Anonymous reporting (for example, by using a cell phone app, such as STOPit) empowers students to report bullying or fights to school staff without risking later retribution from the peer.
“Tough teachers help kids fall in line.”
While peer fights generally increase from 2nd to 4th grade before declining, student fighting progressively increases when teachers use reprimands, rather than praise, to manage their classes. Children look to teachers to learn more than what is in books – how to be respectful and in control without putting others down. The most effective classroom management includes clear, fair rules; any correction should be done privately to avoid shaming students. Students dealt with this way are less likely to be angry and take it out on others. Of course, appropriate services helping every child experience success in learning is the foundation of positive behavior in school.
“Children with ADHD won’t learn self-regulation if they are treated with medicine.”
Children who show “low effortful control” or higher “dysregulation” are both more aggressive and also less likely to decline in aggression in early childhood. ADHD is a neurological condition characterized by such dysregulation and low effortful control. Children with ADHD often have higher and more persistent aggression. These tendencies also result in impulsive behaviors that can irritate peers and adults and can result in correction and criticism, further increasing aggression. Children with ADHD who are better controlled, often with the help of medication, have more positive interactions at school and at home, receive more praise and less correction, and develop more reasoned interaction patterns.
“I am the parent, and my child should do what I say.”
When adults step in to stop a fight, they are rarely in a position to know what actually happened between the kids. Children may quickly learn how to entrap a sibling or peer to look like the perpetrator in order to get them in trouble and/or avoid consequences for themselves, especially if large or harsh punishments are being used.
While it can seem tricky to treat children who are very different in age or development equally, having parents elicit or at least verbalize each child’s point of view is part of how children learn respect and mediation skills. Parents who refrain from taking sides or dictating how disputes should be resolved leave the chance for the children to acquire these component skills of negotiation. This does not mean there are no consequences, just that a brief discussion comes first.
When fighting is a pediatric complaint, you have a great opportunity to educate families in evidence-based ways that can both prevent and reduce their child’s use of aggression.
In one effective 90-minute training program, parents were taught basic mediation principles: to give ground rules and ask their children to agree to them, to ask each child to describe what happened and identify their disagreements and common ground, to encourage the children to discuss their goals in the fight and feelings about the issues, and to encourage the children to come up with suggestions to resolve their disputes and help them assess the practical aspects of their ideas. Praise should be used each time a child uses even some of these skills. Parents in this program also were given communication strategies, such as active listening, reflecting, and reframing, to help children learn to take the others’ perspective. In a follow up survey a month later, children of parents in the intervention group were seen to use these skills in real situations that might otherwise have been fights.
When aggression persists, mindfulness training, cognitive-behavioral techniques, social-emotional approaches, or peer mentoring programs delivered through individual counseling or school programs are all ways of teaching kids important interaction skills to reduce peer aggression. Remember, 40% of severe adult aggression begins before age 8 years, so preventive education or early referral to mental health services is key.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at pdnews@frontlinemedcom.com.
How to deal with aggression delivered by a child’s peers is a common concern and social dilemma for both parents and children. How does a child ward off aggressive peers without getting hurt or in trouble while also not looking weak or whiny? What can parents do to stop their child from being hurt or frightened but also not humiliate them or interfere with their learning important life skills by being over protective?
Children do not want to fight, but they do want to be treated fairly. Frustration, with its associated feelings of anger, is the most common reason for aggression. Being a child is certainly full of its frustrations because, while autonomy and desires are increasing, opportunities expand at a slower rate, particularly for children with developmental weaknesses or economic disadvantage. Fear and a lack of coping skills are other major reasons for resorting to aggressive responses.
Physical bullying affects 21% of students in grades 3-12 and is a risk factor for aggression at all ages. A full one-third of 9th-12th graders report having been in a physical fight in the last year. In grade school age and adolescence, factors known to be associated with peer aggression include the humiliation of school failure, substance use, and anger from experiencing parental or sibling aggression.
One would think a universal goal of parents would be to raise their children to get along with others without fighting. Unfortunately, some parents actually espouse childrearing methods that directly or indirectly make fighting more likely.
Essentially all toddlers and preschoolers can be aggressive at times to get things they want (instrumental) or when angry in the beginning of their second year of life; this peaks in the third year and typically declines after age 3 years. But for some 10% of children, aggression remains high. What parent and child factors set children up for such persistent aggression?
Parents have many reasons for how they raise their children, but some myths about parenting that persist promote aggression.
“My child will love me more if I am more permissive.”
Infants and toddlers develop self-regulation skills better when it is gradually expected of them with encouragement and support from their parents. Parents may feel that they are showing love to their toddler by having a “relaxed” home with few limits and no specific bedtime or rules. These parents also may “rescue” their child from frustrating situations by giving in to their demands or removing them from even mildly stressful situations.
These strategies can interfere with the progressive development of frustration tolerance, a key life skill. A lack of routines, inadequate sleep or food, overstimulation by noise, frightening experiences (including fighting in the home or neighborhood), or violent media exposure sets toddlers up to be out of control and thereby increases dysregulation. In addition, the dysregulated child may then act up, which can invoke punishment from that same parent.
Frustrating toddlers with inconsistent expectations and arbitrary punishment, a common result of low structure, makes the child feel insecure and leads to aggression. Instead, children need small doses of frustration appropriate to their age and encouragement from a supportive adult to problem solve. You can praise (or model), cheering on a child with words such as “Are you stuck? You can do it! Try again,” instead of instantly solving problems for them.
“Spare the rod and spoil the child.”
Parents may feel that they are promoting obedience when they use corporal punishment, thinking this will keep the child out of trouble in society. Instead, corporal punishment is associated with increased aggression toward peers, as well as defiance toward parents. These effects are especially strong when mothers are distant emotionally. As pediatricians, we can educate people on the importance of warm parenting, redirection instead of punishment for younger children, and using small, logical consequences or time out when needed for aggression.
“Just ignore bullies.”
It is a rare child who can follow the command to “ignore” a bully without turning red or getting tears in his or her eyes – making them appealing targets. We can coach parents and kids how to disarm bullies by standing tall, putting hands on hips, making eye contact, and asking the peer a question such as “I do not understand what you’re trying to accomplish.” Learning martial arts also teaches children that they are powerful (but not to fight outside the class) so they can present themselves in this way. Programs that encourage children to get together to confront bullies supported by a school administration that uses comprehensive assessment and habilitation strategies for aggressive students are most effective in reducing aggression in schools. Anonymous reporting (for example, by using a cell phone app, such as STOPit) empowers students to report bullying or fights to school staff without risking later retribution from the peer.
“Tough teachers help kids fall in line.”
While peer fights generally increase from 2nd to 4th grade before declining, student fighting progressively increases when teachers use reprimands, rather than praise, to manage their classes. Children look to teachers to learn more than what is in books – how to be respectful and in control without putting others down. The most effective classroom management includes clear, fair rules; any correction should be done privately to avoid shaming students. Students dealt with this way are less likely to be angry and take it out on others. Of course, appropriate services helping every child experience success in learning is the foundation of positive behavior in school.
“Children with ADHD won’t learn self-regulation if they are treated with medicine.”
Children who show “low effortful control” or higher “dysregulation” are both more aggressive and also less likely to decline in aggression in early childhood. ADHD is a neurological condition characterized by such dysregulation and low effortful control. Children with ADHD often have higher and more persistent aggression. These tendencies also result in impulsive behaviors that can irritate peers and adults and can result in correction and criticism, further increasing aggression. Children with ADHD who are better controlled, often with the help of medication, have more positive interactions at school and at home, receive more praise and less correction, and develop more reasoned interaction patterns.
“I am the parent, and my child should do what I say.”
When adults step in to stop a fight, they are rarely in a position to know what actually happened between the kids. Children may quickly learn how to entrap a sibling or peer to look like the perpetrator in order to get them in trouble and/or avoid consequences for themselves, especially if large or harsh punishments are being used.
While it can seem tricky to treat children who are very different in age or development equally, having parents elicit or at least verbalize each child’s point of view is part of how children learn respect and mediation skills. Parents who refrain from taking sides or dictating how disputes should be resolved leave the chance for the children to acquire these component skills of negotiation. This does not mean there are no consequences, just that a brief discussion comes first.
When fighting is a pediatric complaint, you have a great opportunity to educate families in evidence-based ways that can both prevent and reduce their child’s use of aggression.
In one effective 90-minute training program, parents were taught basic mediation principles: to give ground rules and ask their children to agree to them, to ask each child to describe what happened and identify their disagreements and common ground, to encourage the children to discuss their goals in the fight and feelings about the issues, and to encourage the children to come up with suggestions to resolve their disputes and help them assess the practical aspects of their ideas. Praise should be used each time a child uses even some of these skills. Parents in this program also were given communication strategies, such as active listening, reflecting, and reframing, to help children learn to take the others’ perspective. In a follow up survey a month later, children of parents in the intervention group were seen to use these skills in real situations that might otherwise have been fights.
When aggression persists, mindfulness training, cognitive-behavioral techniques, social-emotional approaches, or peer mentoring programs delivered through individual counseling or school programs are all ways of teaching kids important interaction skills to reduce peer aggression. Remember, 40% of severe adult aggression begins before age 8 years, so preventive education or early referral to mental health services is key.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at pdnews@frontlinemedcom.com.
How to deal with aggression delivered by a child’s peers is a common concern and social dilemma for both parents and children. How does a child ward off aggressive peers without getting hurt or in trouble while also not looking weak or whiny? What can parents do to stop their child from being hurt or frightened but also not humiliate them or interfere with their learning important life skills by being over protective?
Children do not want to fight, but they do want to be treated fairly. Frustration, with its associated feelings of anger, is the most common reason for aggression. Being a child is certainly full of its frustrations because, while autonomy and desires are increasing, opportunities expand at a slower rate, particularly for children with developmental weaknesses or economic disadvantage. Fear and a lack of coping skills are other major reasons for resorting to aggressive responses.
Physical bullying affects 21% of students in grades 3-12 and is a risk factor for aggression at all ages. A full one-third of 9th-12th graders report having been in a physical fight in the last year. In grade school age and adolescence, factors known to be associated with peer aggression include the humiliation of school failure, substance use, and anger from experiencing parental or sibling aggression.
One would think a universal goal of parents would be to raise their children to get along with others without fighting. Unfortunately, some parents actually espouse childrearing methods that directly or indirectly make fighting more likely.
Essentially all toddlers and preschoolers can be aggressive at times to get things they want (instrumental) or when angry in the beginning of their second year of life; this peaks in the third year and typically declines after age 3 years. But for some 10% of children, aggression remains high. What parent and child factors set children up for such persistent aggression?
Parents have many reasons for how they raise their children, but some myths about parenting that persist promote aggression.
“My child will love me more if I am more permissive.”
Infants and toddlers develop self-regulation skills better when it is gradually expected of them with encouragement and support from their parents. Parents may feel that they are showing love to their toddler by having a “relaxed” home with few limits and no specific bedtime or rules. These parents also may “rescue” their child from frustrating situations by giving in to their demands or removing them from even mildly stressful situations.
These strategies can interfere with the progressive development of frustration tolerance, a key life skill. A lack of routines, inadequate sleep or food, overstimulation by noise, frightening experiences (including fighting in the home or neighborhood), or violent media exposure sets toddlers up to be out of control and thereby increases dysregulation. In addition, the dysregulated child may then act up, which can invoke punishment from that same parent.
Frustrating toddlers with inconsistent expectations and arbitrary punishment, a common result of low structure, makes the child feel insecure and leads to aggression. Instead, children need small doses of frustration appropriate to their age and encouragement from a supportive adult to problem solve. You can praise (or model), cheering on a child with words such as “Are you stuck? You can do it! Try again,” instead of instantly solving problems for them.
“Spare the rod and spoil the child.”
Parents may feel that they are promoting obedience when they use corporal punishment, thinking this will keep the child out of trouble in society. Instead, corporal punishment is associated with increased aggression toward peers, as well as defiance toward parents. These effects are especially strong when mothers are distant emotionally. As pediatricians, we can educate people on the importance of warm parenting, redirection instead of punishment for younger children, and using small, logical consequences or time out when needed for aggression.
“Just ignore bullies.”
It is a rare child who can follow the command to “ignore” a bully without turning red or getting tears in his or her eyes – making them appealing targets. We can coach parents and kids how to disarm bullies by standing tall, putting hands on hips, making eye contact, and asking the peer a question such as “I do not understand what you’re trying to accomplish.” Learning martial arts also teaches children that they are powerful (but not to fight outside the class) so they can present themselves in this way. Programs that encourage children to get together to confront bullies supported by a school administration that uses comprehensive assessment and habilitation strategies for aggressive students are most effective in reducing aggression in schools. Anonymous reporting (for example, by using a cell phone app, such as STOPit) empowers students to report bullying or fights to school staff without risking later retribution from the peer.
“Tough teachers help kids fall in line.”
While peer fights generally increase from 2nd to 4th grade before declining, student fighting progressively increases when teachers use reprimands, rather than praise, to manage their classes. Children look to teachers to learn more than what is in books – how to be respectful and in control without putting others down. The most effective classroom management includes clear, fair rules; any correction should be done privately to avoid shaming students. Students dealt with this way are less likely to be angry and take it out on others. Of course, appropriate services helping every child experience success in learning is the foundation of positive behavior in school.
“Children with ADHD won’t learn self-regulation if they are treated with medicine.”
Children who show “low effortful control” or higher “dysregulation” are both more aggressive and also less likely to decline in aggression in early childhood. ADHD is a neurological condition characterized by such dysregulation and low effortful control. Children with ADHD often have higher and more persistent aggression. These tendencies also result in impulsive behaviors that can irritate peers and adults and can result in correction and criticism, further increasing aggression. Children with ADHD who are better controlled, often with the help of medication, have more positive interactions at school and at home, receive more praise and less correction, and develop more reasoned interaction patterns.
“I am the parent, and my child should do what I say.”
When adults step in to stop a fight, they are rarely in a position to know what actually happened between the kids. Children may quickly learn how to entrap a sibling or peer to look like the perpetrator in order to get them in trouble and/or avoid consequences for themselves, especially if large or harsh punishments are being used.
While it can seem tricky to treat children who are very different in age or development equally, having parents elicit or at least verbalize each child’s point of view is part of how children learn respect and mediation skills. Parents who refrain from taking sides or dictating how disputes should be resolved leave the chance for the children to acquire these component skills of negotiation. This does not mean there are no consequences, just that a brief discussion comes first.
When fighting is a pediatric complaint, you have a great opportunity to educate families in evidence-based ways that can both prevent and reduce their child’s use of aggression.
In one effective 90-minute training program, parents were taught basic mediation principles: to give ground rules and ask their children to agree to them, to ask each child to describe what happened and identify their disagreements and common ground, to encourage the children to discuss their goals in the fight and feelings about the issues, and to encourage the children to come up with suggestions to resolve their disputes and help them assess the practical aspects of their ideas. Praise should be used each time a child uses even some of these skills. Parents in this program also were given communication strategies, such as active listening, reflecting, and reframing, to help children learn to take the others’ perspective. In a follow up survey a month later, children of parents in the intervention group were seen to use these skills in real situations that might otherwise have been fights.
When aggression persists, mindfulness training, cognitive-behavioral techniques, social-emotional approaches, or peer mentoring programs delivered through individual counseling or school programs are all ways of teaching kids important interaction skills to reduce peer aggression. Remember, 40% of severe adult aggression begins before age 8 years, so preventive education or early referral to mental health services is key.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at pdnews@frontlinemedcom.com.
Sleepless in adolescence
One thing that constantly surprises me about adolescent sleep is that neither the teen nor the parent is as concerned about it as I am. Instead, they complain about irritability, dropping grades, anxiety, depression, obesity, oppositionality, fatigue, and even substance use – all documented effects of sleep debt.
Inadequate sleep changes the brain, resulting in thinner gray matter, less neuroplasticity, poorer higher-level cognitive abilities (attention, working memory, inhibition, judgment, decision-making), lower motivation, and poorer academic functioning. None of these are losses teens can afford!
While sleep problems are more common in those with mental health disorders, poor sleep precedes anxiety and depression more than the reverse. Sleep problems increase the risk of depression, and depression relapses. Insomnia predicts risk behaviors – drinking and driving, smoking, delinquency. Getting less than 8 hours of sleep is associated with a threefold higher risk of suicide attempts.
Despite these pervasive threats to health and development, instead of concern, I find a lot of resistance in families and teens to taking action to improve sleep.
Teens don’t believe in problems from inadequate sleep. After all, they say, their peers are “all” getting the same amount of sleep. And they are largely correct – 75% of U.S. 12th graders get less than 8 hours of sleep. But the data are clear that children aged 12-18 years need 8.25-9.25 hours of sleep.
Parents generally are not aware of how little sleep their teens are getting because they go to bed on their own. If parents do check, any teenagers worth the label can growl their way out of supervision, “promise” to shut off the lights, or feign sleep. Having the house, pantry, and electronics to themselves at night is worth the risk of a consequence, especially for those who would rather avoid interacting.
The social forces keeping teens up at night are their “life”: the hours required for homework can be the reason for inadequate sleep. In subgroups of teens, sports practices, employment, or family responsibilities may extend the day past a bedtime needed for optimal sleep.
But use of electronics – the lifeline of adolescents – is responsible for much of their sleep debt. Electronic devices both delay sleep onset and reduce sleep duration. After 9:00 p.m., 34% of children aged older than 12 years are text messaging, 44% are talking, 55% are online, and 24% are playing computer games. Use of a TV or tablet at bedtime results in reduced sleep, and increased poor quality of sleep. Three or more hours of TV result not only in difficulty falling asleep and frequent awakenings, but also sleep issues later as adults. Shooter video games result in lower sleepiness, longer sleep latency, and shorter REM sleep. Even the low level light from electronic devices alters circadian rhythm and suppresses nocturnal melatonin secretion.
Keep in mind the biological reasons teens go to bed later. One is the typical emotional hyperarousal of being a teen. But other biological forces are at work in adolescence, such as reduction in the accumulation of sleep pressure during wakefulness and delaying the melatonin release that produces sleepiness. Teens (and parents) think sleeping in on weekends takes care of inadequate weekday sleep, but this so-called “recovery sleep” tends to occur at an inappropriate time in the circadian phase and further delays melatonin production, as well as reducing sleep pressure, making it even harder to fall asleep.
In some cases, medications we prescribe – such as stimulants, theophylline, antihistamines, or anticonvulsants – are at fault for delaying or disturbing sleep. But more often it is self-administered substances that are part of the teen’s attempt to stay awake – including nicotine, alcohol, and caffeine – that produce shorter sleep duration, increased latency to sleep, more wake time during sleep, and increased daytime sleepiness; it results in a vicious cycle. Sleep disruption may explain the association of these substances with less memory consolidation, poorer academic performance, and higher rates of risk behaviors.
We adults also are a cause of teen sleep debt. We are the ones allowing the early school start times for teens, primarily to allow for after school sports programs that glorify the school and bring kudos to some at the expense of all the students. A 65-minute earlier start in 10th grade resulted in less than half of students getting 7 hours of sleep or more. The level of resulting sleepiness is equal to that of narcolepsy.
As primary care clinicians, we can and need to detect, educate about, and treat sleep debt and sleep disorders. Sleep questionnaires can help. Treatment of sleep includes coaching for: having a cool, dark room used mainly for sleep; a regular schedule 7 days per week; avoiding exercise within 2 hours of bedtime; avoiding stimulants such as caffeine, tea, nicotine, and medications at least 3 hours before bedtime; keeping to a routine with no daytime naps; and especially no media in the bedroom! For teens already not able to sleep until early morning, you can recommend that they work bedtime back or forward by 1 hour per day until hitting a time that will allow 9 hours of sleep. Alternatively, have them stay up all night to reset their biological clock. Subsequently, the sleep schedule has to stay within 1 hour for sleep and waking 7 days per week. Anxious teens, besides needing therapy, may need a soothing routine, no visible clock, and a plan to get back up for 1 hour every time it takes longer than 10 minutes to fall asleep.
If sleepy teens report adequate time in bed, then we need to understand pathologies such as obstructive sleep apnea, restless legs syndrome, menstruation-related or primary hypersomnias, and narcolepsy to diagnose and resolve the problem.
Parents may have given up protecting their teens from inadequate sleep so we as health providers need to do so.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at pdnews@frontlinemedcom.com.
One thing that constantly surprises me about adolescent sleep is that neither the teen nor the parent is as concerned about it as I am. Instead, they complain about irritability, dropping grades, anxiety, depression, obesity, oppositionality, fatigue, and even substance use – all documented effects of sleep debt.
Inadequate sleep changes the brain, resulting in thinner gray matter, less neuroplasticity, poorer higher-level cognitive abilities (attention, working memory, inhibition, judgment, decision-making), lower motivation, and poorer academic functioning. None of these are losses teens can afford!
While sleep problems are more common in those with mental health disorders, poor sleep precedes anxiety and depression more than the reverse. Sleep problems increase the risk of depression, and depression relapses. Insomnia predicts risk behaviors – drinking and driving, smoking, delinquency. Getting less than 8 hours of sleep is associated with a threefold higher risk of suicide attempts.
Despite these pervasive threats to health and development, instead of concern, I find a lot of resistance in families and teens to taking action to improve sleep.
Teens don’t believe in problems from inadequate sleep. After all, they say, their peers are “all” getting the same amount of sleep. And they are largely correct – 75% of U.S. 12th graders get less than 8 hours of sleep. But the data are clear that children aged 12-18 years need 8.25-9.25 hours of sleep.
Parents generally are not aware of how little sleep their teens are getting because they go to bed on their own. If parents do check, any teenagers worth the label can growl their way out of supervision, “promise” to shut off the lights, or feign sleep. Having the house, pantry, and electronics to themselves at night is worth the risk of a consequence, especially for those who would rather avoid interacting.
The social forces keeping teens up at night are their “life”: the hours required for homework can be the reason for inadequate sleep. In subgroups of teens, sports practices, employment, or family responsibilities may extend the day past a bedtime needed for optimal sleep.
But use of electronics – the lifeline of adolescents – is responsible for much of their sleep debt. Electronic devices both delay sleep onset and reduce sleep duration. After 9:00 p.m., 34% of children aged older than 12 years are text messaging, 44% are talking, 55% are online, and 24% are playing computer games. Use of a TV or tablet at bedtime results in reduced sleep, and increased poor quality of sleep. Three or more hours of TV result not only in difficulty falling asleep and frequent awakenings, but also sleep issues later as adults. Shooter video games result in lower sleepiness, longer sleep latency, and shorter REM sleep. Even the low level light from electronic devices alters circadian rhythm and suppresses nocturnal melatonin secretion.
Keep in mind the biological reasons teens go to bed later. One is the typical emotional hyperarousal of being a teen. But other biological forces are at work in adolescence, such as reduction in the accumulation of sleep pressure during wakefulness and delaying the melatonin release that produces sleepiness. Teens (and parents) think sleeping in on weekends takes care of inadequate weekday sleep, but this so-called “recovery sleep” tends to occur at an inappropriate time in the circadian phase and further delays melatonin production, as well as reducing sleep pressure, making it even harder to fall asleep.
In some cases, medications we prescribe – such as stimulants, theophylline, antihistamines, or anticonvulsants – are at fault for delaying or disturbing sleep. But more often it is self-administered substances that are part of the teen’s attempt to stay awake – including nicotine, alcohol, and caffeine – that produce shorter sleep duration, increased latency to sleep, more wake time during sleep, and increased daytime sleepiness; it results in a vicious cycle. Sleep disruption may explain the association of these substances with less memory consolidation, poorer academic performance, and higher rates of risk behaviors.
We adults also are a cause of teen sleep debt. We are the ones allowing the early school start times for teens, primarily to allow for after school sports programs that glorify the school and bring kudos to some at the expense of all the students. A 65-minute earlier start in 10th grade resulted in less than half of students getting 7 hours of sleep or more. The level of resulting sleepiness is equal to that of narcolepsy.
As primary care clinicians, we can and need to detect, educate about, and treat sleep debt and sleep disorders. Sleep questionnaires can help. Treatment of sleep includes coaching for: having a cool, dark room used mainly for sleep; a regular schedule 7 days per week; avoiding exercise within 2 hours of bedtime; avoiding stimulants such as caffeine, tea, nicotine, and medications at least 3 hours before bedtime; keeping to a routine with no daytime naps; and especially no media in the bedroom! For teens already not able to sleep until early morning, you can recommend that they work bedtime back or forward by 1 hour per day until hitting a time that will allow 9 hours of sleep. Alternatively, have them stay up all night to reset their biological clock. Subsequently, the sleep schedule has to stay within 1 hour for sleep and waking 7 days per week. Anxious teens, besides needing therapy, may need a soothing routine, no visible clock, and a plan to get back up for 1 hour every time it takes longer than 10 minutes to fall asleep.
If sleepy teens report adequate time in bed, then we need to understand pathologies such as obstructive sleep apnea, restless legs syndrome, menstruation-related or primary hypersomnias, and narcolepsy to diagnose and resolve the problem.
Parents may have given up protecting their teens from inadequate sleep so we as health providers need to do so.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at pdnews@frontlinemedcom.com.
One thing that constantly surprises me about adolescent sleep is that neither the teen nor the parent is as concerned about it as I am. Instead, they complain about irritability, dropping grades, anxiety, depression, obesity, oppositionality, fatigue, and even substance use – all documented effects of sleep debt.
Inadequate sleep changes the brain, resulting in thinner gray matter, less neuroplasticity, poorer higher-level cognitive abilities (attention, working memory, inhibition, judgment, decision-making), lower motivation, and poorer academic functioning. None of these are losses teens can afford!
While sleep problems are more common in those with mental health disorders, poor sleep precedes anxiety and depression more than the reverse. Sleep problems increase the risk of depression, and depression relapses. Insomnia predicts risk behaviors – drinking and driving, smoking, delinquency. Getting less than 8 hours of sleep is associated with a threefold higher risk of suicide attempts.
Despite these pervasive threats to health and development, instead of concern, I find a lot of resistance in families and teens to taking action to improve sleep.
Teens don’t believe in problems from inadequate sleep. After all, they say, their peers are “all” getting the same amount of sleep. And they are largely correct – 75% of U.S. 12th graders get less than 8 hours of sleep. But the data are clear that children aged 12-18 years need 8.25-9.25 hours of sleep.
Parents generally are not aware of how little sleep their teens are getting because they go to bed on their own. If parents do check, any teenagers worth the label can growl their way out of supervision, “promise” to shut off the lights, or feign sleep. Having the house, pantry, and electronics to themselves at night is worth the risk of a consequence, especially for those who would rather avoid interacting.
The social forces keeping teens up at night are their “life”: the hours required for homework can be the reason for inadequate sleep. In subgroups of teens, sports practices, employment, or family responsibilities may extend the day past a bedtime needed for optimal sleep.
But use of electronics – the lifeline of adolescents – is responsible for much of their sleep debt. Electronic devices both delay sleep onset and reduce sleep duration. After 9:00 p.m., 34% of children aged older than 12 years are text messaging, 44% are talking, 55% are online, and 24% are playing computer games. Use of a TV or tablet at bedtime results in reduced sleep, and increased poor quality of sleep. Three or more hours of TV result not only in difficulty falling asleep and frequent awakenings, but also sleep issues later as adults. Shooter video games result in lower sleepiness, longer sleep latency, and shorter REM sleep. Even the low level light from electronic devices alters circadian rhythm and suppresses nocturnal melatonin secretion.
Keep in mind the biological reasons teens go to bed later. One is the typical emotional hyperarousal of being a teen. But other biological forces are at work in adolescence, such as reduction in the accumulation of sleep pressure during wakefulness and delaying the melatonin release that produces sleepiness. Teens (and parents) think sleeping in on weekends takes care of inadequate weekday sleep, but this so-called “recovery sleep” tends to occur at an inappropriate time in the circadian phase and further delays melatonin production, as well as reducing sleep pressure, making it even harder to fall asleep.
In some cases, medications we prescribe – such as stimulants, theophylline, antihistamines, or anticonvulsants – are at fault for delaying or disturbing sleep. But more often it is self-administered substances that are part of the teen’s attempt to stay awake – including nicotine, alcohol, and caffeine – that produce shorter sleep duration, increased latency to sleep, more wake time during sleep, and increased daytime sleepiness; it results in a vicious cycle. Sleep disruption may explain the association of these substances with less memory consolidation, poorer academic performance, and higher rates of risk behaviors.
We adults also are a cause of teen sleep debt. We are the ones allowing the early school start times for teens, primarily to allow for after school sports programs that glorify the school and bring kudos to some at the expense of all the students. A 65-minute earlier start in 10th grade resulted in less than half of students getting 7 hours of sleep or more. The level of resulting sleepiness is equal to that of narcolepsy.
As primary care clinicians, we can and need to detect, educate about, and treat sleep debt and sleep disorders. Sleep questionnaires can help. Treatment of sleep includes coaching for: having a cool, dark room used mainly for sleep; a regular schedule 7 days per week; avoiding exercise within 2 hours of bedtime; avoiding stimulants such as caffeine, tea, nicotine, and medications at least 3 hours before bedtime; keeping to a routine with no daytime naps; and especially no media in the bedroom! For teens already not able to sleep until early morning, you can recommend that they work bedtime back or forward by 1 hour per day until hitting a time that will allow 9 hours of sleep. Alternatively, have them stay up all night to reset their biological clock. Subsequently, the sleep schedule has to stay within 1 hour for sleep and waking 7 days per week. Anxious teens, besides needing therapy, may need a soothing routine, no visible clock, and a plan to get back up for 1 hour every time it takes longer than 10 minutes to fall asleep.
If sleepy teens report adequate time in bed, then we need to understand pathologies such as obstructive sleep apnea, restless legs syndrome, menstruation-related or primary hypersomnias, and narcolepsy to diagnose and resolve the problem.
Parents may have given up protecting their teens from inadequate sleep so we as health providers need to do so.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at pdnews@frontlinemedcom.com.
You can help with behavior of children with autism spectrum disorder
There are lots of reasons you may be eager to refer children with autism spectrum disorder (ASD) to specialty agencies. You want the fastest possible entry for the child into intervention and the families into a support system. , as well as the general health care, of their children.
“Wait!” you say, “I do not have the special knowledge to help with behavior of children with autism! There is much you can and should do, however, as the specialist(s) may not provide such guidance, entry into behavioral services may take months, and behavior issues may feel urgent to families.
So pick an example of a behavior that is concerning to the family. One problem might be lack of cooperation with activities of daily living such as eating. In this case, the A is being asked to stop playing and sit at the table; the B may be refusing to eat what is served or even to sit very long, ending in a tantrum that disrupts the family meal; and the C could be the child being sent from the table to play on their iPad. But what is the G?
Lack of social communication skills, restrictive interests, hypersensitivity, lack of coordination, and ADHD all may be playing a role. Lack of communication skills makes the social aspect of meals uninteresting. Giving verbal reasons for joining the family may not be effective. Hypersensitivity often is associated with extremes of food selectivity. Lack of fine motor coordination makes eating soup a challenge. And ADHD makes sitting for a long time difficult!
But what about that tantrum? Tantrums that are reinforced by allowing the child to leave and play on the iPad easily can turn into a chronic escape mechanism. Instead, parents need to watch for increasing restlessness, and allow the child to signal “all done” and be “excused” before any tantrum begins. Use of the iPad (a reward) should not be allowed until the family meal is over for everyone. Such accommodations are best decided on by all caregivers in advance, ideally also involving the higher-functioning child. A caregiver who persists in thinking that the child “should” be able to behave may be in denial or grief, and deserves counseling on ASD.
But he is so rigid, the parents say! The tendency of children with ASD to like sameness can be an asset to easing behavior. The key is to design and stick to routines as much as possible, 7 days per week. If the meal is at the same time each day, in the same seat, with the same plate, with no iPad, and the child is allowed to leave only after requesting to, the entire sequence is likely to be smoother. While flexibility does not come easily, it is acquired from the natural variability in family life, but only gradually and over time.
Creating and rehearsing “social stories” is an evidence-based way to help children with ASD have acceptable behaviors. Books, storyboards, and visual schedulers can be purchased to help. But even taking photos or a video of the components of a task and posting this online (private YouTube channel) or on the refrigerator, to review before, during, and/or after the activity, builds an internal image for the child. Children with ASD often watch the same YouTube videos over and over again, and even memorize and use chunks of the speech or songs at other times. Families can capitalize on this kind of repetition by using routines and songs to improve skills.
What to do when she only cares about her iPad? It is sometimes difficult to identify reinforcers to use to strengthen desired behaviors in a child with ASD. A smile or a hug or even candy may not be valued. Help parents think about an object, song, or touch the child tends to like. Media are a strong reinforcer, but need to be used sparingly, in specific situations, and kept under parental control, or else removing them can become a major source of upsets.
When a child with ASD gets upset or even violent, the behavior may be interpreted as defiance; it may scare or upset the whole family, and is not conducive to problem solving. Siblings may start screaming or begging for the parents to stop the behavior. While this creates a crisis, you can advise parents to first ensure that everyone is safe, take deep breaths, and then think about which gap is being stressed. A subtle change from what the child expected – new furniture, a guest at the table, a day off from school, or being interrupted mid video – can cause panic, especially for anxious children. Children with ASD also may act up when uncomfortable from a headache, tooth pain, constipation, hunger, or lack of sleep, but often are unable to vocalize the reason, even if they are verbal. Having parents make a few notes about the As, Bs, Cs, and Gs of each event (the essence of a functional behavioral assessment) to review with the child, each other, the teacher, or you is key to understanding the child with ASD and successfully shifting his behavior.
Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
There are lots of reasons you may be eager to refer children with autism spectrum disorder (ASD) to specialty agencies. You want the fastest possible entry for the child into intervention and the families into a support system. , as well as the general health care, of their children.
“Wait!” you say, “I do not have the special knowledge to help with behavior of children with autism! There is much you can and should do, however, as the specialist(s) may not provide such guidance, entry into behavioral services may take months, and behavior issues may feel urgent to families.
So pick an example of a behavior that is concerning to the family. One problem might be lack of cooperation with activities of daily living such as eating. In this case, the A is being asked to stop playing and sit at the table; the B may be refusing to eat what is served or even to sit very long, ending in a tantrum that disrupts the family meal; and the C could be the child being sent from the table to play on their iPad. But what is the G?
Lack of social communication skills, restrictive interests, hypersensitivity, lack of coordination, and ADHD all may be playing a role. Lack of communication skills makes the social aspect of meals uninteresting. Giving verbal reasons for joining the family may not be effective. Hypersensitivity often is associated with extremes of food selectivity. Lack of fine motor coordination makes eating soup a challenge. And ADHD makes sitting for a long time difficult!
But what about that tantrum? Tantrums that are reinforced by allowing the child to leave and play on the iPad easily can turn into a chronic escape mechanism. Instead, parents need to watch for increasing restlessness, and allow the child to signal “all done” and be “excused” before any tantrum begins. Use of the iPad (a reward) should not be allowed until the family meal is over for everyone. Such accommodations are best decided on by all caregivers in advance, ideally also involving the higher-functioning child. A caregiver who persists in thinking that the child “should” be able to behave may be in denial or grief, and deserves counseling on ASD.
But he is so rigid, the parents say! The tendency of children with ASD to like sameness can be an asset to easing behavior. The key is to design and stick to routines as much as possible, 7 days per week. If the meal is at the same time each day, in the same seat, with the same plate, with no iPad, and the child is allowed to leave only after requesting to, the entire sequence is likely to be smoother. While flexibility does not come easily, it is acquired from the natural variability in family life, but only gradually and over time.
Creating and rehearsing “social stories” is an evidence-based way to help children with ASD have acceptable behaviors. Books, storyboards, and visual schedulers can be purchased to help. But even taking photos or a video of the components of a task and posting this online (private YouTube channel) or on the refrigerator, to review before, during, and/or after the activity, builds an internal image for the child. Children with ASD often watch the same YouTube videos over and over again, and even memorize and use chunks of the speech or songs at other times. Families can capitalize on this kind of repetition by using routines and songs to improve skills.
What to do when she only cares about her iPad? It is sometimes difficult to identify reinforcers to use to strengthen desired behaviors in a child with ASD. A smile or a hug or even candy may not be valued. Help parents think about an object, song, or touch the child tends to like. Media are a strong reinforcer, but need to be used sparingly, in specific situations, and kept under parental control, or else removing them can become a major source of upsets.
When a child with ASD gets upset or even violent, the behavior may be interpreted as defiance; it may scare or upset the whole family, and is not conducive to problem solving. Siblings may start screaming or begging for the parents to stop the behavior. While this creates a crisis, you can advise parents to first ensure that everyone is safe, take deep breaths, and then think about which gap is being stressed. A subtle change from what the child expected – new furniture, a guest at the table, a day off from school, or being interrupted mid video – can cause panic, especially for anxious children. Children with ASD also may act up when uncomfortable from a headache, tooth pain, constipation, hunger, or lack of sleep, but often are unable to vocalize the reason, even if they are verbal. Having parents make a few notes about the As, Bs, Cs, and Gs of each event (the essence of a functional behavioral assessment) to review with the child, each other, the teacher, or you is key to understanding the child with ASD and successfully shifting his behavior.
Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
There are lots of reasons you may be eager to refer children with autism spectrum disorder (ASD) to specialty agencies. You want the fastest possible entry for the child into intervention and the families into a support system. , as well as the general health care, of their children.
“Wait!” you say, “I do not have the special knowledge to help with behavior of children with autism! There is much you can and should do, however, as the specialist(s) may not provide such guidance, entry into behavioral services may take months, and behavior issues may feel urgent to families.
So pick an example of a behavior that is concerning to the family. One problem might be lack of cooperation with activities of daily living such as eating. In this case, the A is being asked to stop playing and sit at the table; the B may be refusing to eat what is served or even to sit very long, ending in a tantrum that disrupts the family meal; and the C could be the child being sent from the table to play on their iPad. But what is the G?
Lack of social communication skills, restrictive interests, hypersensitivity, lack of coordination, and ADHD all may be playing a role. Lack of communication skills makes the social aspect of meals uninteresting. Giving verbal reasons for joining the family may not be effective. Hypersensitivity often is associated with extremes of food selectivity. Lack of fine motor coordination makes eating soup a challenge. And ADHD makes sitting for a long time difficult!
But what about that tantrum? Tantrums that are reinforced by allowing the child to leave and play on the iPad easily can turn into a chronic escape mechanism. Instead, parents need to watch for increasing restlessness, and allow the child to signal “all done” and be “excused” before any tantrum begins. Use of the iPad (a reward) should not be allowed until the family meal is over for everyone. Such accommodations are best decided on by all caregivers in advance, ideally also involving the higher-functioning child. A caregiver who persists in thinking that the child “should” be able to behave may be in denial or grief, and deserves counseling on ASD.
But he is so rigid, the parents say! The tendency of children with ASD to like sameness can be an asset to easing behavior. The key is to design and stick to routines as much as possible, 7 days per week. If the meal is at the same time each day, in the same seat, with the same plate, with no iPad, and the child is allowed to leave only after requesting to, the entire sequence is likely to be smoother. While flexibility does not come easily, it is acquired from the natural variability in family life, but only gradually and over time.
Creating and rehearsing “social stories” is an evidence-based way to help children with ASD have acceptable behaviors. Books, storyboards, and visual schedulers can be purchased to help. But even taking photos or a video of the components of a task and posting this online (private YouTube channel) or on the refrigerator, to review before, during, and/or after the activity, builds an internal image for the child. Children with ASD often watch the same YouTube videos over and over again, and even memorize and use chunks of the speech or songs at other times. Families can capitalize on this kind of repetition by using routines and songs to improve skills.
What to do when she only cares about her iPad? It is sometimes difficult to identify reinforcers to use to strengthen desired behaviors in a child with ASD. A smile or a hug or even candy may not be valued. Help parents think about an object, song, or touch the child tends to like. Media are a strong reinforcer, but need to be used sparingly, in specific situations, and kept under parental control, or else removing them can become a major source of upsets.
When a child with ASD gets upset or even violent, the behavior may be interpreted as defiance; it may scare or upset the whole family, and is not conducive to problem solving. Siblings may start screaming or begging for the parents to stop the behavior. While this creates a crisis, you can advise parents to first ensure that everyone is safe, take deep breaths, and then think about which gap is being stressed. A subtle change from what the child expected – new furniture, a guest at the table, a day off from school, or being interrupted mid video – can cause panic, especially for anxious children. Children with ASD also may act up when uncomfortable from a headache, tooth pain, constipation, hunger, or lack of sleep, but often are unable to vocalize the reason, even if they are verbal. Having parents make a few notes about the As, Bs, Cs, and Gs of each event (the essence of a functional behavioral assessment) to review with the child, each other, the teacher, or you is key to understanding the child with ASD and successfully shifting his behavior.
Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
Mindfulness and child health
If you are struggling to figure out how you, as an individual pediatrician, can make a significant impact on the most common current issues in child health of anxiety, depression, sleep problems, stress, and even adverse childhood experiences, you are not alone. Many of the problems we see in the office appear to stem so much from the culture in which we live that the medical interventions we have to offer seem paltry. Yet we strive to identify and attempt to ameliorate the child’s and family’s distress.
Real physical danger aside, a lot of personal distress is due to negative thoughts about one’s past or fears for one’s future. These thoughts are very important in restraining us from repeating mistakes and preparing us for action to prevent future harm. But the thoughts themselves can be stressful; they may paralyze us with anxiety, take away pleasure, interrupt our sleep, stimulate physiologic stress responses, and have adverse impacts on health. All these effects can occur without actually changing the course of events! How can we advise our patients and their parents to work to balance the protective function of our thoughts against the cost to our well-being?
One promising method you can confidently recommend to both children and their parents to manage stressful thinking is to learn and practice mindfulness. Mindfulness refers to a state of nonreactivity, awareness, focus, attention, and nonjudgment. Noticing thoughts and feelings passing through us with a neutral mind, as if we were watching a movie, rather than taking them personally, is the goal. Jon Kabat-Zinn, PhD, learned from Buddhists, then developed and disseminated a formal program to teach this skill called mindfulness-based stress reduction; it has yielded significant benefits to the emotions and health of adult participants. While everyone can be mindful at times, the ability to enter this state at will and maintain it for a few minutes can be learned, even by preschool children.
How am I going to refer my patients to mindfulness programs, I can hear you saying, when I can’t even get them to standard therapies? Mindfulness in a less-structured format is often part of yoga or Tai Chi, meditation, art therapy, group therapy, or even religious services. Fortunately, parents and educators also can teach children mindfulness. But the first way you can start making this life skill available to your patients is by recommending it to their parents (“The Family ADHD Solution” by Mark Bertin [New York: Palgrave MacMillan, 2011]).
You know that child emotional or behavior problems can cause adult stress. But adult stress also can cause or exacerbate a child’s emotional or behavior problems. Adult caregivers modeling meltdowns are shaping the minds of their children. Studies of teaching mindfulness to parents of children with developmental disabilities, autism, and ADHD, without touching the underlying disorder, show significant reductions in both adult stress and child behavior problems. Parents who can suspend emotion, take some deep breaths, and be thoughtful about the response they want to make instead of reacting impulsively act more reasonably, appear warmer and more compassionate to their children, and are often rewarded with better behavior. Such parents may feel better about themselves and their parenting, may experience less stress, and may themselves sleep better at night!
For children, having an adult simply declare moments to stop, take deep breaths, and notice the sounds, sights, feelings, and smells around them is a good start. Making a routine of taking an “awareness walk” around the block can be another lesson. Eating a food, such as a strawberry, mindfully – observing and savoring every bite – is another natural opportunity to practice increased awareness. One of my favorite tools, having a child shake a glitter globe (like a snow globe that can be made at home) and silently wait for the chaos to subside, “just like their feelings inside,” is soothing and a great metaphor! Abdominal breathing, part of many relaxation exercises, may be hard for young children to master. A parent might try having the child lie down with a stuffed animal on his or her belly and focus on watching it rise and fall while breathing as a way to learn this. For older children, keeping a “gratitude journal” helps focus on the positive, and also has some proven efficacy in relieving depression. Using the “1 Second Everyday” app to video a special moment daily may have a similar effect on sharpening awareness.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
If you are struggling to figure out how you, as an individual pediatrician, can make a significant impact on the most common current issues in child health of anxiety, depression, sleep problems, stress, and even adverse childhood experiences, you are not alone. Many of the problems we see in the office appear to stem so much from the culture in which we live that the medical interventions we have to offer seem paltry. Yet we strive to identify and attempt to ameliorate the child’s and family’s distress.
Real physical danger aside, a lot of personal distress is due to negative thoughts about one’s past or fears for one’s future. These thoughts are very important in restraining us from repeating mistakes and preparing us for action to prevent future harm. But the thoughts themselves can be stressful; they may paralyze us with anxiety, take away pleasure, interrupt our sleep, stimulate physiologic stress responses, and have adverse impacts on health. All these effects can occur without actually changing the course of events! How can we advise our patients and their parents to work to balance the protective function of our thoughts against the cost to our well-being?
One promising method you can confidently recommend to both children and their parents to manage stressful thinking is to learn and practice mindfulness. Mindfulness refers to a state of nonreactivity, awareness, focus, attention, and nonjudgment. Noticing thoughts and feelings passing through us with a neutral mind, as if we were watching a movie, rather than taking them personally, is the goal. Jon Kabat-Zinn, PhD, learned from Buddhists, then developed and disseminated a formal program to teach this skill called mindfulness-based stress reduction; it has yielded significant benefits to the emotions and health of adult participants. While everyone can be mindful at times, the ability to enter this state at will and maintain it for a few minutes can be learned, even by preschool children.
How am I going to refer my patients to mindfulness programs, I can hear you saying, when I can’t even get them to standard therapies? Mindfulness in a less-structured format is often part of yoga or Tai Chi, meditation, art therapy, group therapy, or even religious services. Fortunately, parents and educators also can teach children mindfulness. But the first way you can start making this life skill available to your patients is by recommending it to their parents (“The Family ADHD Solution” by Mark Bertin [New York: Palgrave MacMillan, 2011]).
You know that child emotional or behavior problems can cause adult stress. But adult stress also can cause or exacerbate a child’s emotional or behavior problems. Adult caregivers modeling meltdowns are shaping the minds of their children. Studies of teaching mindfulness to parents of children with developmental disabilities, autism, and ADHD, without touching the underlying disorder, show significant reductions in both adult stress and child behavior problems. Parents who can suspend emotion, take some deep breaths, and be thoughtful about the response they want to make instead of reacting impulsively act more reasonably, appear warmer and more compassionate to their children, and are often rewarded with better behavior. Such parents may feel better about themselves and their parenting, may experience less stress, and may themselves sleep better at night!
For children, having an adult simply declare moments to stop, take deep breaths, and notice the sounds, sights, feelings, and smells around them is a good start. Making a routine of taking an “awareness walk” around the block can be another lesson. Eating a food, such as a strawberry, mindfully – observing and savoring every bite – is another natural opportunity to practice increased awareness. One of my favorite tools, having a child shake a glitter globe (like a snow globe that can be made at home) and silently wait for the chaos to subside, “just like their feelings inside,” is soothing and a great metaphor! Abdominal breathing, part of many relaxation exercises, may be hard for young children to master. A parent might try having the child lie down with a stuffed animal on his or her belly and focus on watching it rise and fall while breathing as a way to learn this. For older children, keeping a “gratitude journal” helps focus on the positive, and also has some proven efficacy in relieving depression. Using the “1 Second Everyday” app to video a special moment daily may have a similar effect on sharpening awareness.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
If you are struggling to figure out how you, as an individual pediatrician, can make a significant impact on the most common current issues in child health of anxiety, depression, sleep problems, stress, and even adverse childhood experiences, you are not alone. Many of the problems we see in the office appear to stem so much from the culture in which we live that the medical interventions we have to offer seem paltry. Yet we strive to identify and attempt to ameliorate the child’s and family’s distress.
Real physical danger aside, a lot of personal distress is due to negative thoughts about one’s past or fears for one’s future. These thoughts are very important in restraining us from repeating mistakes and preparing us for action to prevent future harm. But the thoughts themselves can be stressful; they may paralyze us with anxiety, take away pleasure, interrupt our sleep, stimulate physiologic stress responses, and have adverse impacts on health. All these effects can occur without actually changing the course of events! How can we advise our patients and their parents to work to balance the protective function of our thoughts against the cost to our well-being?
One promising method you can confidently recommend to both children and their parents to manage stressful thinking is to learn and practice mindfulness. Mindfulness refers to a state of nonreactivity, awareness, focus, attention, and nonjudgment. Noticing thoughts and feelings passing through us with a neutral mind, as if we were watching a movie, rather than taking them personally, is the goal. Jon Kabat-Zinn, PhD, learned from Buddhists, then developed and disseminated a formal program to teach this skill called mindfulness-based stress reduction; it has yielded significant benefits to the emotions and health of adult participants. While everyone can be mindful at times, the ability to enter this state at will and maintain it for a few minutes can be learned, even by preschool children.
How am I going to refer my patients to mindfulness programs, I can hear you saying, when I can’t even get them to standard therapies? Mindfulness in a less-structured format is often part of yoga or Tai Chi, meditation, art therapy, group therapy, or even religious services. Fortunately, parents and educators also can teach children mindfulness. But the first way you can start making this life skill available to your patients is by recommending it to their parents (“The Family ADHD Solution” by Mark Bertin [New York: Palgrave MacMillan, 2011]).
You know that child emotional or behavior problems can cause adult stress. But adult stress also can cause or exacerbate a child’s emotional or behavior problems. Adult caregivers modeling meltdowns are shaping the minds of their children. Studies of teaching mindfulness to parents of children with developmental disabilities, autism, and ADHD, without touching the underlying disorder, show significant reductions in both adult stress and child behavior problems. Parents who can suspend emotion, take some deep breaths, and be thoughtful about the response they want to make instead of reacting impulsively act more reasonably, appear warmer and more compassionate to their children, and are often rewarded with better behavior. Such parents may feel better about themselves and their parenting, may experience less stress, and may themselves sleep better at night!
For children, having an adult simply declare moments to stop, take deep breaths, and notice the sounds, sights, feelings, and smells around them is a good start. Making a routine of taking an “awareness walk” around the block can be another lesson. Eating a food, such as a strawberry, mindfully – observing and savoring every bite – is another natural opportunity to practice increased awareness. One of my favorite tools, having a child shake a glitter globe (like a snow globe that can be made at home) and silently wait for the chaos to subside, “just like their feelings inside,” is soothing and a great metaphor! Abdominal breathing, part of many relaxation exercises, may be hard for young children to master. A parent might try having the child lie down with a stuffed animal on his or her belly and focus on watching it rise and fall while breathing as a way to learn this. For older children, keeping a “gratitude journal” helps focus on the positive, and also has some proven efficacy in relieving depression. Using the “1 Second Everyday” app to video a special moment daily may have a similar effect on sharpening awareness.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
Solving stool refusal
When parents bring in their delightful, verbal 3-year-old for refusing to poop on the potty, it may seem laughable. But with impending preschool and costs of diapers, stool refusal can be a major aggravation for families! Fortunately,
Commonly a healthy, typically developing boy stands and urinates in the toilet just fine, but sneaks off behind the sofa to poop. Parent gyrations have gone from cajoling, to punishing, to offering trips to Disney! Flaring tempers can set the stage for stool refusal to be a power play.
There are a number of reasons stool refusal may give clues to child and family tendencies and relevant intervention. We always should be alert to rare medical problems such as Hirschsprung disease or traumas (from slammed toilet lids to sexual abuse). But while learning to use the toilet for urination and defecation generally occur around the same time, there are pitfalls making pooping in the potty different. An impending stool provides stronger sensations and more advance warning than urine and tends to come at regular times, making it logical to start toilet learning with sitting on the potty after meals.
But once seated on the potty, stools can require some waiting – not a typical toddler forte! While running to sit has novelty at first and may be reinforced by celebration, this quickly becomes routine and boring. Very active or very intense children especially hate having their play interrupted by a trip to the bathroom. Oppositional children just won’t perform if they think the parent cares! And unlike for urination, everyone can inhibit defecation long enough for the urge to pass. Repeated stool retention from ignoring the urge makes stools dessicated and harder, with resulting pain when finally passed. One painful stool makes many a young child decide “Never again!” and simply refuse the toilet. A rectal fissure can both start 
During unclogging and establishing a new stool pattern, the toddler should be matter-of-factly put back in diapers (not pull ups) saying “Oh well, you are just not ready for pants yet.” Dramatically placing the treasured Superhero underwear on the top shelf increases motivation (or promised if none have been acquired). Returning to diapers without shaming the child is key, and all caregivers need to buy in. They need to be good “actors,” conveying that they don’t really care about toileting to reduce the power struggle. If controlling poop is a battle, only the child can win!
When the soft stools are occurring several times per day, I suggest “M&M treatment”: 1 for sitting, 2 for peeing, and 3 for pooping = 6 potential M&Ms per episode. The “1 for sitting” (the easiest part), is not painful and restores the habit of complying. Remember, M&Ms are no match for a game on an iPad! By charting the times of stools, the parent can remove electronics ½ hour before the expected poop and restrict the child to one room of the house with a potty nearby. Parents can interact, but should avoid making this a rewarding playtime. When the child uses the potty rather than their pants, the room restriction is removed until the next window for pooping. If they poop outside the toilet, they remain restricted (and no electronics) until the next window (even the next day).
Some parents are especially sensitive to the smell and mess of stools and pass that attitude along to their child by saying “Ugh, you stink!” or “I can’t stand this mess!” or even handing the child to another caregiver in a gesture of rejection. These messages are not missed by the child, who may then not want to deal with the mess, either. I coach parents to stay at least neutral about stools, reminding them that, “Your child is going to have to poop her whole life!”
Demanding a diaper and then getting the special intimacy of bottom cleaning can be reinforcing. If there is a younger sibling, diaper changes may be a desired opportunity for the toddler to regress and retain some “baby privileges.” Other clues to this dynamic include thumb sucking, baby talk, clinginess, or being rough on the sibling. One part of addressing this issue is to prescribe “babying” the toddler by holding in arms, rocking, talking baby talk, offering a pacifier, and feeding him during daily parent-child one-on-one Special Time. This sounds crazy to parents aiming for grown up toileting, but I promise them the child will not go backwards! It addresses the child’s deep fear that the nurturing of infancy is no longer available.
You may have noticed that boys are much more likely to refuse stools than girls. Some of this difference may be that high activity, but learning to urinate standing up also is fun, a Big Boy feat, and a source of pride to fathers. If regular sitting to poop has not been well established before the fun of standing to pee is offered, the little guys are not so interested in sitting again to poop. Plus the wiping and hand washing after poops are further aggravations delaying return to the Legos. But more! By around age 3 years, both genders make the horrifying discovery that boys have a penis and girls don’t. At this age of confusion about potential transformations, the obvious conclusion is that the girl’s penis was lost! And that turd disappearing down the toilet looks a lot like a dismembered body part! Reassurance and education is in order. I address this with my “Penis Talk”: “Boys are made with a penis and girls are made with a vagina. (For boys:) When you get big like your Dad, your penis will be big, too. No one can ever take your penis away. (For girls, a less common concern.) You have always had a vagina. You did not lose a penis.” I recommend that you practice this in front of a mirror before first use!
Another cognitive milestone concerns what sorts of things can disappear dow
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at pdnews@frontlinemedcom.com.
When parents bring in their delightful, verbal 3-year-old for refusing to poop on the potty, it may seem laughable. But with impending preschool and costs of diapers, stool refusal can be a major aggravation for families! Fortunately,
Commonly a healthy, typically developing boy stands and urinates in the toilet just fine, but sneaks off behind the sofa to poop. Parent gyrations have gone from cajoling, to punishing, to offering trips to Disney! Flaring tempers can set the stage for stool refusal to be a power play.
There are a number of reasons stool refusal may give clues to child and family tendencies and relevant intervention. We always should be alert to rare medical problems such as Hirschsprung disease or traumas (from slammed toilet lids to sexual abuse). But while learning to use the toilet for urination and defecation generally occur around the same time, there are pitfalls making pooping in the potty different. An impending stool provides stronger sensations and more advance warning than urine and tends to come at regular times, making it logical to start toilet learning with sitting on the potty after meals.
But once seated on the potty, stools can require some waiting – not a typical toddler forte! While running to sit has novelty at first and may be reinforced by celebration, this quickly becomes routine and boring. Very active or very intense children especially hate having their play interrupted by a trip to the bathroom. Oppositional children just won’t perform if they think the parent cares! And unlike for urination, everyone can inhibit defecation long enough for the urge to pass. Repeated stool retention from ignoring the urge makes stools dessicated and harder, with resulting pain when finally passed. One painful stool makes many a young child decide “Never again!” and simply refuse the toilet. A rectal fissure can both start
During unclogging and establishing a new stool pattern, the toddler should be matter-of-factly put back in diapers (not pull ups) saying “Oh well, you are just not ready for pants yet.” Dramatically placing the treasured Superhero underwear on the top shelf increases motivation (or promised if none have been acquired). Returning to diapers without shaming the child is key, and all caregivers need to buy in. They need to be good “actors,” conveying that they don’t really care about toileting to reduce the power struggle. If controlling poop is a battle, only the child can win!
When the soft stools are occurring several times per day, I suggest “M&M treatment”: 1 for sitting, 2 for peeing, and 3 for pooping = 6 potential M&Ms per episode. The “1 for sitting” (the easiest part), is not painful and restores the habit of complying. Remember, M&Ms are no match for a game on an iPad! By charting the times of stools, the parent can remove electronics ½ hour before the expected poop and restrict the child to one room of the house with a potty nearby. Parents can interact, but should avoid making this a rewarding playtime. When the child uses the potty rather than their pants, the room restriction is removed until the next window for pooping. If they poop outside the toilet, they remain restricted (and no electronics) until the next window (even the next day).
Some parents are especially sensitive to the smell and mess of stools and pass that attitude along to their child by saying “Ugh, you stink!” or “I can’t stand this mess!” or even handing the child to another caregiver in a gesture of rejection. These messages are not missed by the child, who may then not want to deal with the mess, either. I coach parents to stay at least neutral about stools, reminding them that, “Your child is going to have to poop her whole life!”
Demanding a diaper and then getting the special intimacy of bottom cleaning can be reinforcing. If there is a younger sibling, diaper changes may be a desired opportunity for the toddler to regress and retain some “baby privileges.” Other clues to this dynamic include thumb sucking, baby talk, clinginess, or being rough on the sibling. One part of addressing this issue is to prescribe “babying” the toddler by holding in arms, rocking, talking baby talk, offering a pacifier, and feeding him during daily parent-child one-on-one Special Time. This sounds crazy to parents aiming for grown up toileting, but I promise them the child will not go backwards! It addresses the child’s deep fear that the nurturing of infancy is no longer available.
You may have noticed that boys are much more likely to refuse stools than girls. Some of this difference may be that high activity, but learning to urinate standing up also is fun, a Big Boy feat, and a source of pride to fathers. If regular sitting to poop has not been well established before the fun of standing to pee is offered, the little guys are not so interested in sitting again to poop. Plus the wiping and hand washing after poops are further aggravations delaying return to the Legos. But more! By around age 3 years, both genders make the horrifying discovery that boys have a penis and girls don’t. At this age of confusion about potential transformations, the obvious conclusion is that the girl’s penis was lost! And that turd disappearing down the toilet looks a lot like a dismembered body part! Reassurance and education is in order. I address this with my “Penis Talk”: “Boys are made with a penis and girls are made with a vagina. (For boys:) When you get big like your Dad, your penis will be big, too. No one can ever take your penis away. (For girls, a less common concern.) You have always had a vagina. You did not lose a penis.” I recommend that you practice this in front of a mirror before first use!
Another cognitive milestone concerns what sorts of things can disappear dow
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at pdnews@frontlinemedcom.com.
When parents bring in their delightful, verbal 3-year-old for refusing to poop on the potty, it may seem laughable. But with impending preschool and costs of diapers, stool refusal can be a major aggravation for families! Fortunately,
Commonly a healthy, typically developing boy stands and urinates in the toilet just fine, but sneaks off behind the sofa to poop. Parent gyrations have gone from cajoling, to punishing, to offering trips to Disney! Flaring tempers can set the stage for stool refusal to be a power play.
There are a number of reasons stool refusal may give clues to child and family tendencies and relevant intervention. We always should be alert to rare medical problems such as Hirschsprung disease or traumas (from slammed toilet lids to sexual abuse). But while learning to use the toilet for urination and defecation generally occur around the same time, there are pitfalls making pooping in the potty different. An impending stool provides stronger sensations and more advance warning than urine and tends to come at regular times, making it logical to start toilet learning with sitting on the potty after meals.
But once seated on the potty, stools can require some waiting – not a typical toddler forte! While running to sit has novelty at first and may be reinforced by celebration, this quickly becomes routine and boring. Very active or very intense children especially hate having their play interrupted by a trip to the bathroom. Oppositional children just won’t perform if they think the parent cares! And unlike for urination, everyone can inhibit defecation long enough for the urge to pass. Repeated stool retention from ignoring the urge makes stools dessicated and harder, with resulting pain when finally passed. One painful stool makes many a young child decide “Never again!” and simply refuse the toilet. A rectal fissure can both start
During unclogging and establishing a new stool pattern, the toddler should be matter-of-factly put back in diapers (not pull ups) saying “Oh well, you are just not ready for pants yet.” Dramatically placing the treasured Superhero underwear on the top shelf increases motivation (or promised if none have been acquired). Returning to diapers without shaming the child is key, and all caregivers need to buy in. They need to be good “actors,” conveying that they don’t really care about toileting to reduce the power struggle. If controlling poop is a battle, only the child can win!
When the soft stools are occurring several times per day, I suggest “M&M treatment”: 1 for sitting, 2 for peeing, and 3 for pooping = 6 potential M&Ms per episode. The “1 for sitting” (the easiest part), is not painful and restores the habit of complying. Remember, M&Ms are no match for a game on an iPad! By charting the times of stools, the parent can remove electronics ½ hour before the expected poop and restrict the child to one room of the house with a potty nearby. Parents can interact, but should avoid making this a rewarding playtime. When the child uses the potty rather than their pants, the room restriction is removed until the next window for pooping. If they poop outside the toilet, they remain restricted (and no electronics) until the next window (even the next day).
Some parents are especially sensitive to the smell and mess of stools and pass that attitude along to their child by saying “Ugh, you stink!” or “I can’t stand this mess!” or even handing the child to another caregiver in a gesture of rejection. These messages are not missed by the child, who may then not want to deal with the mess, either. I coach parents to stay at least neutral about stools, reminding them that, “Your child is going to have to poop her whole life!”
Demanding a diaper and then getting the special intimacy of bottom cleaning can be reinforcing. If there is a younger sibling, diaper changes may be a desired opportunity for the toddler to regress and retain some “baby privileges.” Other clues to this dynamic include thumb sucking, baby talk, clinginess, or being rough on the sibling. One part of addressing this issue is to prescribe “babying” the toddler by holding in arms, rocking, talking baby talk, offering a pacifier, and feeding him during daily parent-child one-on-one Special Time. This sounds crazy to parents aiming for grown up toileting, but I promise them the child will not go backwards! It addresses the child’s deep fear that the nurturing of infancy is no longer available.
You may have noticed that boys are much more likely to refuse stools than girls. Some of this difference may be that high activity, but learning to urinate standing up also is fun, a Big Boy feat, and a source of pride to fathers. If regular sitting to poop has not been well established before the fun of standing to pee is offered, the little guys are not so interested in sitting again to poop. Plus the wiping and hand washing after poops are further aggravations delaying return to the Legos. But more! By around age 3 years, both genders make the horrifying discovery that boys have a penis and girls don’t. At this age of confusion about potential transformations, the obvious conclusion is that the girl’s penis was lost! And that turd disappearing down the toilet looks a lot like a dismembered body part! Reassurance and education is in order. I address this with my “Penis Talk”: “Boys are made with a penis and girls are made with a vagina. (For boys:) When you get big like your Dad, your penis will be big, too. No one can ever take your penis away. (For girls, a less common concern.) You have always had a vagina. You did not lose a penis.” I recommend that you practice this in front of a mirror before first use!
Another cognitive milestone concerns what sorts of things can disappear dow
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at pdnews@frontlinemedcom.com.
What, you never filled the prescription?!
How many times do you come out of the exam room after seeing a patient in follow-up and heave a sigh because the parents did not give their child the medicine as you prescribed it?
Without adherence to the medication plan, a lot of suboptimal outcomes can and do occur. A urinary tract infection may come back partially treated, requiring a more extensive work-up. A strep infection may spread to family members. Inflammatory bowel disease may require bowel resection. Asthma may simmer with long-term inflammation and pulmonary compromise as well as concurrent activity limitations. Often children with asthma are given less than 50% of prescribed controller medicines. In one pediatric study, medication adherence was not even asked about in 66% of cases. In adults, 20%-30% of prescriptions are never filled.
As physicians, we are carefully schooled in making complex diagnoses, sorting out and prioritizing the laboratory work-up, and memorizing the latest and most effective treatment regimens. What is rarely taught, however, is how to conduct the conversation needed to optimize subsequent adherence to the medication plan.
Problem-solving counseling is an evidence-based method to improve medication adherence. This is a semistructured form of cognitive-behavioral intervention designed to engage the responsible person (parent or child) in shared decision making about whether and how to take medication, and which one to take. After all, for good or for bad, it is really their choice!
1. Problem definition. This step involves developing a clear and specific definition of the problem. Educating families about a medical condition has to start with asking what they already know. This often includes sagas of bad outcomes in relatives. Ask: Who do you know with asthma? How was it for them? The family needs to know symptoms, simple pathophysiology (such as inflammation you can’t see or feel), course, and prognosis. They also need to know where their child’s condition falls on the continuum. And they need to understand the essential prevention aspect of controllers in what appears to be an asymptomatic child. Failure to communicate this is a common reason for nonadherence in asthma.
2. Generation of alternatives. This involves brainstorming to identify multiple and creative solutions. This step will reveal past experiences as well as things the family learned on the Internet that may be true and relevant, or true but irrelevant, or false. Ask: What have you heard about treatments for asthma? What do you think would be best for your child? Generic handouts with a sampling of medicines, advantages and disadvantages, side effects, and costs of the main choices have been shown to be helpful guides that enhance adherence through empowering the family in their choice and reassuring family members that you have been thorough. It can be a balancing act to describe possible side effects without scaring the family into shutting down and being unable to make any choice at all. However, failure to discuss common effects they may notice – such as a racing heart from rescue medications – but that you think of as trivial, may also lead to nonadherence. A way to communicate about perceived side effects and manage them has to be part of an effective plan. Planning a phone or email check-in can make a big difference.
3. Decision making. This step involves evaluating all the solutions to identify the most effective and feasible option. Once the family understands the problem and the alternatives, it is crucial for you, as the physician, to not only ask their preference but be ready to suggest what you think would be best. While not wanting to be patronized, families want your opinion. I like to have family members close their eyes and visualize carrying out the selected routine. This is a good hypnotic technique for future remembering, but you also may discover important facts by this simple exercise, such as that the child gets up alone for school, making morning dosing unreliable. Shared decision making is not a way to abdicate your expert opinion, just to incorporate family preferences and factors.
4. Solution implementation. This step involves carrying out the plan. There is no substitute for a real life trial! There may be surprising issues: Autistic children may be afraid of a nebulizer machine. Sensitive children may refuse the flavor of some inhalers.
5. Solution verification. Evaluate the effectiveness of the solution and modify the plan as necessary. Follow-up contact is crucial, especially at the start of a new chronic medication plan. When families know that the plan can be changed if things do not go well or they change their minds, they will be less fearful of giving it a try and more honest about barriers they perceive or encounter rather than simply showing up at the next visit with the child’s condition out of control.
Although using problem-solving counseling may sound complicated, it is intended to be focused and brief, and has been shown to be feasibly done in the clinic by primary care providers, without lengthening the visit. CHADIS even has teleprompter text specific to parent-reported barriers to help you.
Even when family members understand and agrees to a medication plan during the visit, there are a variety of reasons they may not adhere to it. They may forget to give the medicine, be unable to afford it once prescribed, experience unpleasant side effects, encounter resistance from the child, or get unanticipated push back from family members. All of these issues can be addressed if you know that they happen. You just have to ask! Recommending smartphone reminders or reminder apps (such as Medisafe), using GoodRx to find cheaper sources, suggesting candy as a chaser, recommending behavior strategies for feisty kids, and providing written materials (or a phone call) for reluctant relatives are strategies you can prepare in advance to have in your quiver and are well worth your time.
If it weren’t enough to address adherence to optimize outcomes, asthma management and control will likely be a Clinical Quality Measure, determining how we will be paid starting this year. Now you have a tool to do it!
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
How many times do you come out of the exam room after seeing a patient in follow-up and heave a sigh because the parents did not give their child the medicine as you prescribed it?
Without adherence to the medication plan, a lot of suboptimal outcomes can and do occur. A urinary tract infection may come back partially treated, requiring a more extensive work-up. A strep infection may spread to family members. Inflammatory bowel disease may require bowel resection. Asthma may simmer with long-term inflammation and pulmonary compromise as well as concurrent activity limitations. Often children with asthma are given less than 50% of prescribed controller medicines. In one pediatric study, medication adherence was not even asked about in 66% of cases. In adults, 20%-30% of prescriptions are never filled.
As physicians, we are carefully schooled in making complex diagnoses, sorting out and prioritizing the laboratory work-up, and memorizing the latest and most effective treatment regimens. What is rarely taught, however, is how to conduct the conversation needed to optimize subsequent adherence to the medication plan.
Problem-solving counseling is an evidence-based method to improve medication adherence. This is a semistructured form of cognitive-behavioral intervention designed to engage the responsible person (parent or child) in shared decision making about whether and how to take medication, and which one to take. After all, for good or for bad, it is really their choice!
1. Problem definition. This step involves developing a clear and specific definition of the problem. Educating families about a medical condition has to start with asking what they already know. This often includes sagas of bad outcomes in relatives. Ask: Who do you know with asthma? How was it for them? The family needs to know symptoms, simple pathophysiology (such as inflammation you can’t see or feel), course, and prognosis. They also need to know where their child’s condition falls on the continuum. And they need to understand the essential prevention aspect of controllers in what appears to be an asymptomatic child. Failure to communicate this is a common reason for nonadherence in asthma.
2. Generation of alternatives. This involves brainstorming to identify multiple and creative solutions. This step will reveal past experiences as well as things the family learned on the Internet that may be true and relevant, or true but irrelevant, or false. Ask: What have you heard about treatments for asthma? What do you think would be best for your child? Generic handouts with a sampling of medicines, advantages and disadvantages, side effects, and costs of the main choices have been shown to be helpful guides that enhance adherence through empowering the family in their choice and reassuring family members that you have been thorough. It can be a balancing act to describe possible side effects without scaring the family into shutting down and being unable to make any choice at all. However, failure to discuss common effects they may notice – such as a racing heart from rescue medications – but that you think of as trivial, may also lead to nonadherence. A way to communicate about perceived side effects and manage them has to be part of an effective plan. Planning a phone or email check-in can make a big difference.
3. Decision making. This step involves evaluating all the solutions to identify the most effective and feasible option. Once the family understands the problem and the alternatives, it is crucial for you, as the physician, to not only ask their preference but be ready to suggest what you think would be best. While not wanting to be patronized, families want your opinion. I like to have family members close their eyes and visualize carrying out the selected routine. This is a good hypnotic technique for future remembering, but you also may discover important facts by this simple exercise, such as that the child gets up alone for school, making morning dosing unreliable. Shared decision making is not a way to abdicate your expert opinion, just to incorporate family preferences and factors.
4. Solution implementation. This step involves carrying out the plan. There is no substitute for a real life trial! There may be surprising issues: Autistic children may be afraid of a nebulizer machine. Sensitive children may refuse the flavor of some inhalers.
5. Solution verification. Evaluate the effectiveness of the solution and modify the plan as necessary. Follow-up contact is crucial, especially at the start of a new chronic medication plan. When families know that the plan can be changed if things do not go well or they change their minds, they will be less fearful of giving it a try and more honest about barriers they perceive or encounter rather than simply showing up at the next visit with the child’s condition out of control.
Although using problem-solving counseling may sound complicated, it is intended to be focused and brief, and has been shown to be feasibly done in the clinic by primary care providers, without lengthening the visit. CHADIS even has teleprompter text specific to parent-reported barriers to help you.
Even when family members understand and agrees to a medication plan during the visit, there are a variety of reasons they may not adhere to it. They may forget to give the medicine, be unable to afford it once prescribed, experience unpleasant side effects, encounter resistance from the child, or get unanticipated push back from family members. All of these issues can be addressed if you know that they happen. You just have to ask! Recommending smartphone reminders or reminder apps (such as Medisafe), using GoodRx to find cheaper sources, suggesting candy as a chaser, recommending behavior strategies for feisty kids, and providing written materials (or a phone call) for reluctant relatives are strategies you can prepare in advance to have in your quiver and are well worth your time.
If it weren’t enough to address adherence to optimize outcomes, asthma management and control will likely be a Clinical Quality Measure, determining how we will be paid starting this year. Now you have a tool to do it!
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
How many times do you come out of the exam room after seeing a patient in follow-up and heave a sigh because the parents did not give their child the medicine as you prescribed it?
Without adherence to the medication plan, a lot of suboptimal outcomes can and do occur. A urinary tract infection may come back partially treated, requiring a more extensive work-up. A strep infection may spread to family members. Inflammatory bowel disease may require bowel resection. Asthma may simmer with long-term inflammation and pulmonary compromise as well as concurrent activity limitations. Often children with asthma are given less than 50% of prescribed controller medicines. In one pediatric study, medication adherence was not even asked about in 66% of cases. In adults, 20%-30% of prescriptions are never filled.
As physicians, we are carefully schooled in making complex diagnoses, sorting out and prioritizing the laboratory work-up, and memorizing the latest and most effective treatment regimens. What is rarely taught, however, is how to conduct the conversation needed to optimize subsequent adherence to the medication plan.
Problem-solving counseling is an evidence-based method to improve medication adherence. This is a semistructured form of cognitive-behavioral intervention designed to engage the responsible person (parent or child) in shared decision making about whether and how to take medication, and which one to take. After all, for good or for bad, it is really their choice!
1. Problem definition. This step involves developing a clear and specific definition of the problem. Educating families about a medical condition has to start with asking what they already know. This often includes sagas of bad outcomes in relatives. Ask: Who do you know with asthma? How was it for them? The family needs to know symptoms, simple pathophysiology (such as inflammation you can’t see or feel), course, and prognosis. They also need to know where their child’s condition falls on the continuum. And they need to understand the essential prevention aspect of controllers in what appears to be an asymptomatic child. Failure to communicate this is a common reason for nonadherence in asthma.
2. Generation of alternatives. This involves brainstorming to identify multiple and creative solutions. This step will reveal past experiences as well as things the family learned on the Internet that may be true and relevant, or true but irrelevant, or false. Ask: What have you heard about treatments for asthma? What do you think would be best for your child? Generic handouts with a sampling of medicines, advantages and disadvantages, side effects, and costs of the main choices have been shown to be helpful guides that enhance adherence through empowering the family in their choice and reassuring family members that you have been thorough. It can be a balancing act to describe possible side effects without scaring the family into shutting down and being unable to make any choice at all. However, failure to discuss common effects they may notice – such as a racing heart from rescue medications – but that you think of as trivial, may also lead to nonadherence. A way to communicate about perceived side effects and manage them has to be part of an effective plan. Planning a phone or email check-in can make a big difference.
3. Decision making. This step involves evaluating all the solutions to identify the most effective and feasible option. Once the family understands the problem and the alternatives, it is crucial for you, as the physician, to not only ask their preference but be ready to suggest what you think would be best. While not wanting to be patronized, families want your opinion. I like to have family members close their eyes and visualize carrying out the selected routine. This is a good hypnotic technique for future remembering, but you also may discover important facts by this simple exercise, such as that the child gets up alone for school, making morning dosing unreliable. Shared decision making is not a way to abdicate your expert opinion, just to incorporate family preferences and factors.
4. Solution implementation. This step involves carrying out the plan. There is no substitute for a real life trial! There may be surprising issues: Autistic children may be afraid of a nebulizer machine. Sensitive children may refuse the flavor of some inhalers.
5. Solution verification. Evaluate the effectiveness of the solution and modify the plan as necessary. Follow-up contact is crucial, especially at the start of a new chronic medication plan. When families know that the plan can be changed if things do not go well or they change their minds, they will be less fearful of giving it a try and more honest about barriers they perceive or encounter rather than simply showing up at the next visit with the child’s condition out of control.
Although using problem-solving counseling may sound complicated, it is intended to be focused and brief, and has been shown to be feasibly done in the clinic by primary care providers, without lengthening the visit. CHADIS even has teleprompter text specific to parent-reported barriers to help you.
Even when family members understand and agrees to a medication plan during the visit, there are a variety of reasons they may not adhere to it. They may forget to give the medicine, be unable to afford it once prescribed, experience unpleasant side effects, encounter resistance from the child, or get unanticipated push back from family members. All of these issues can be addressed if you know that they happen. You just have to ask! Recommending smartphone reminders or reminder apps (such as Medisafe), using GoodRx to find cheaper sources, suggesting candy as a chaser, recommending behavior strategies for feisty kids, and providing written materials (or a phone call) for reluctant relatives are strategies you can prepare in advance to have in your quiver and are well worth your time.
If it weren’t enough to address adherence to optimize outcomes, asthma management and control will likely be a Clinical Quality Measure, determining how we will be paid starting this year. Now you have a tool to do it!
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
50 years of child psychiatry, developmental-behavioral pediatrics
The 50th anniversary of Pediatric News prompts us to look back on the past 50 years in child psychiatry and developmental-behavioral pediatrics, and reflect on the evolution of the field. This includes the approach to diagnosis, the thinking about development and family, and the approach and access to treatment during this dynamic period.
While some historians identify the establishment of the first juvenile court in Chicago in 1899 and the work to help judges evaluate juvenile delinquency as the origin of child psychiatry in the United States, it was not until after World War II that the field really began to take root here, largely based on psychiatrists fleeing Europe and the seminal work of Anna Freud. Some of the earliest connections between pediatrics and child psychiatry were based on the work in England of Donald W. Winnicott, a practicing pediatrician and child psychiatrist, Albert J. Solnit, MD, at the Yale Child Study Center, and psychologically informed work of pediatrician Benjamin M. Spock, MD.
The first Diagnostic and Statistical Manual (DSM) was published in 1952, based on a codification of mental disorders established by the Navy during WWII. The American Academy of Child & Adolescent Psychiatry was established in 1953, the same year that the first “tranquilizer,” chlorpromazine (Thorazine) was introduced (in France), marking the start of a revolution in psychiatric care. In 1959, the first candidates sat for a licensing examination in child psychiatry. The Section on Developmental and Behavioral Pediatrics was established as part of the American Academy of Pediatrics in 1960 to support training in this area. The AACAP established a journal in 1961. Child guidance clinics started affiliating with hospitals and universities in the 1960’s, after the Community Mental Health Act of 1963. Then, in 1965, Julius B. Richmond, MD, (a pediatrician) and Uri Bronfenbrenner, PhD, (a developmental psychologist), recognizing the importance of ecological systems to child development, were involved in the creation of Head Start, and the first Joint Commission on Mental Health for Children was established by federal legislation in 1965. The field was truly coalescing into a distinct discipline of medicine, one that bridged pediatrics, psychiatry, and neurology with nonmedical disciplines such as justice and education.
The decade between 1967 and 1977 was a period of transition from the focus on psychoanalytic concepts typical of the first half of the century to a more systematic approach to diagnosis. Children in psychiatric treatment had commonly been seen for extended individual treatments, and those with more disruptive disorders often were hospitalized for long periods. Psychoanalysis focused on the unconscious (theoretical drives and conflicts) to guide treatment. Treatment often focused on the role (causal) of parents, and family treatment was common, even on inpatient units. The second edition of the DSM (DSM-II) was published in 1968, with its first distinct section for disorders of childhood and adolescence, and an overarching focus on psychodynamics. In 1974, the decision was made to publish a new edition of the DSM that would establish a multiaxial assessment system (separating “biological” mental health problems from personality disorders, medical illnesses, and psychosocial stressors) and research-oriented diagnostic criteria that would attempt to facilitate reliable diagnoses based on common clusters of symptoms. Field trials sponsored by the National Institute of Mental Health began in 1977 to establish the reliability of the new diagnoses.
The year 1977 saw the first Apple computer, the New York City blackout, the release of the first “Star Wars” movie, and also the start of a momentous decade in general and child psychiatry. The third edition of the DSM (DSM-III) was published in 1980, the beginning of a revolution in psychiatric diagnosis and treatments. It created reliable, reproducible diagnostic constructs to serve as the basis for studies on epidemiology and treatment. Implications of causality were replaced by description; for example, hyperkinetic reaction of childhood was redefined and labeled attention-deficit disorder. Recognizing the importance of research and training in this rapidly changing field, W.T. Grant Foundation funded 11 fellowship programs in 1977, and the Society for Developmental and Behavioral Pediatrics was founded in 1982 by the leaders of those programs.
In 1983, The AACAP published “Child Psychiatry: A Plan for the Coming Decades.” It was the result of 5 years’ work by 100 child psychiatrists, general psychiatrists, pediatricians, epidemiologists, nurses, leaders of the NIMH, and various child advocates. This report laid out a challenge for child psychiatry to develop research strategies that would allow evidence-based understanding and treatment of the mental illnesses of children. The established focus on individual experience and anecdotal data, particularly about social and psychodynamic influences, would shift towards a more scientific approach to diagnosis and treatment. This decade started an explosion in epidemiologic research, medication trials, and controlled studies of nonbiological treatments in child psychiatry. At the same time, the political landscape changed, and an ascendant conservatism began the process of closing publicly funded residential treatment centers that had offered care to the more chronically mentally ill and children with profound developmental disorders. This would accelerate the shift towards outpatient psychiatric care of children. Ironically, as research would accelerate in child psychiatry, access to effective treatments would become more difficult.
The decade from 1987 to 1997 was a period of dramatic growth in medication use in child psychiatry. Prozac was approved by the Food and Drug Administration for use in the United States in 1988 and soon followed by other selective serotonin reuptake inhibitors (Zoloft in 1991 and Paxil in 1992). The journal of the AACAP began to publish more randomized controlled trials of medication treatments in children with DSM-codified diagnoses, and clinicians became more comfortable using stimulants, antidepressants, and even antipsychotic medications in the outpatient setting. This trend was enhanced by the emergence of managed care and the denial of coverage for alleged “nonbiological” diagnoses and for many psychiatric treatments. Loss of reimbursement led to a significant decline in resources, particularly inpatient child psychiatry beds and specialized clinics. This, in turn, contributed to the growing emphasis on medication treatments for children’s mental health problems. For-profit managed care companies underbid each other to provide mental health coverage and incentivized medication visits. Of note, the medical budgets, not the mental health carve outs, were billed for the medication prescribed.
The Americans with Disabilities Act was passed in 1990, increasing the funding for school-based mental health resources for children, and in 1996, Congress passed the Mental Health Parity Act, the first of several legislative attempts to ensure parity between insurance coverage for medical and psychiatric illnesses – legislation that to this day has not achieved parity of access to care. As pediatricians took on more of mental health care, a multidisciplinary team created a primary care version of DSM IV, the DSM-IV-PC, in 1995, to assist with defining levels of symptoms less than disorder to facilitate earlier intervention. A formal subspecialty of developmental-behavioral pediatrics was established in 1999 to educate leaders. Pediatric residents have had required training in developmental-behavioral pediatrics since 2008.
The year 1997 saw the first nationwide survey of parents about attention-deficit/hyperactivity disorder, kicking off what could be called the decade of ADHD, in which prevalence rates steadily climbed, from 5.7% in 1997 to 9.5% in 2007. The prevalence of stimulant treatment in children skyrocketed in this period. According to the NIMH, stimulants were prescribed to 4.2% of 6- to 12-year-olds in 1996, and that number grew to 5.1% in 2008. For 13- to 18-year-olds, the rate more than doubled during this time, from 2.3% in 1996 to 4.9% in 2008. The prevalence of autism also grew dramatically during this time, from 1.9 per 1,000 in 1997-1999 to 7.4 per 1,000 in 2006-2008, probably based on an evolving understanding of the disorder and this diagnosis providing special access to resources in schools.
Research during this decade became increasingly focused on imaging studies of children (and adults), as leaders in the field were trying to move from symptom clusters to anatomic and physiologic correlates of psychiatric illness. The great increase in medication use in children hit a speed bump in October 2004, when the Food and Drug Administration issued a controversial public warning about an increased risk of suicidal thoughts or behaviors in youth being treated with SSRI antidepressants. As access to child psychiatric treatment had become more difficult over the preceding decades, pediatricians had assumed much of the medication treatment of common psychiatric problems. The FDA’s black box warning complicated pediatricians’ efforts to fill this void.
The last decade has been the decade of genetics and efforts to improve access to care. It started in 2007 with the FDA expanding its SSRI warning to acknowledge that depression itself increased the risk for suicide, in an effort to not discourage needed depression treatment in young people. But studies demonstrated that the rates of diagnosing and treating depression dropped dramatically in the years following the warning: Diagnoses of depression declined by as much as 42% in children, and the rate of antidepressant treatment in adolescents dropped by as much as 32% in the 2 years following the warning (N Engl J Med. 2014 Oct 30;371(18):1666-8). There was no compensatory increase in utilization of other kinds of treatments. While suicide rates in young people had been stubbornly steady from the mid-1970’s to the mid-1990’s, they began to decline in 1996, according to the Centers for Disease Control and Prevention. But that trend was broken in 2004, with a jump in attempted and completed suicides in young people. The rate stabilized later in the decade, but has never returned to the lows that were being achieved prior to the warning.
This decade was marked by the passage of the Affordable Care Act, including – again – an unfulfilled mandate for mental health parity for any insurance plans in the marketplace. Although diagnosis is still symptom based, the effort to define psychiatric disorders based on brain anatomy, neurotransmitters, and genomics continues to intensify. There is growing evidence that psychiatric disorders are not nature or nurture, but nature and nurture. Epigenetic findings show that environment impacts gene expression and brain functioning. These findings promise to deepen our understanding of the critical role of early experiences (consider Adverse Childhood Experiences [ACE] scores) and the promise of protective relationships, in schools and parenting.
And what will come next? We believe that silos – medical, psychiatric, parenting, school, environment – will be bridged to understand the many factors that impact behavior and treatment, but the need to advocate for policies that support funding for the education and mental health care of children and the training of professionals to provide that care is never ending. As our knowledge of the genome marches forward, we may discover effective strategies for preventing the emergence of mental illness in children or create individualized treatments. We may learn more about the role of nutrition and the microbiome in health and disease, about autoimmunity and mental illness. Our focus may return to parents, not as culprits, but as the mediators of health from the prenatal period on. Technology may enable us to improve access to effective treatments, with teens monitoring their sleep and mood, and accessing therapy on their smart phones. And our understanding of development and vulnerability may help us stem the rise in autism or collaborate with educators so that education could better put every child on their healthiest possible path. We look forward to experiencing it – and writing about it – with you!
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. They said they had no relevant financial disclosures. Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email them at pdnews@frontlinemedcom.com.
The 50th anniversary of Pediatric News prompts us to look back on the past 50 years in child psychiatry and developmental-behavioral pediatrics, and reflect on the evolution of the field. This includes the approach to diagnosis, the thinking about development and family, and the approach and access to treatment during this dynamic period.
While some historians identify the establishment of the first juvenile court in Chicago in 1899 and the work to help judges evaluate juvenile delinquency as the origin of child psychiatry in the United States, it was not until after World War II that the field really began to take root here, largely based on psychiatrists fleeing Europe and the seminal work of Anna Freud. Some of the earliest connections between pediatrics and child psychiatry were based on the work in England of Donald W. Winnicott, a practicing pediatrician and child psychiatrist, Albert J. Solnit, MD, at the Yale Child Study Center, and psychologically informed work of pediatrician Benjamin M. Spock, MD.
The first Diagnostic and Statistical Manual (DSM) was published in 1952, based on a codification of mental disorders established by the Navy during WWII. The American Academy of Child & Adolescent Psychiatry was established in 1953, the same year that the first “tranquilizer,” chlorpromazine (Thorazine) was introduced (in France), marking the start of a revolution in psychiatric care. In 1959, the first candidates sat for a licensing examination in child psychiatry. The Section on Developmental and Behavioral Pediatrics was established as part of the American Academy of Pediatrics in 1960 to support training in this area. The AACAP established a journal in 1961. Child guidance clinics started affiliating with hospitals and universities in the 1960’s, after the Community Mental Health Act of 1963. Then, in 1965, Julius B. Richmond, MD, (a pediatrician) and Uri Bronfenbrenner, PhD, (a developmental psychologist), recognizing the importance of ecological systems to child development, were involved in the creation of Head Start, and the first Joint Commission on Mental Health for Children was established by federal legislation in 1965. The field was truly coalescing into a distinct discipline of medicine, one that bridged pediatrics, psychiatry, and neurology with nonmedical disciplines such as justice and education.
The decade between 1967 and 1977 was a period of transition from the focus on psychoanalytic concepts typical of the first half of the century to a more systematic approach to diagnosis. Children in psychiatric treatment had commonly been seen for extended individual treatments, and those with more disruptive disorders often were hospitalized for long periods. Psychoanalysis focused on the unconscious (theoretical drives and conflicts) to guide treatment. Treatment often focused on the role (causal) of parents, and family treatment was common, even on inpatient units. The second edition of the DSM (DSM-II) was published in 1968, with its first distinct section for disorders of childhood and adolescence, and an overarching focus on psychodynamics. In 1974, the decision was made to publish a new edition of the DSM that would establish a multiaxial assessment system (separating “biological” mental health problems from personality disorders, medical illnesses, and psychosocial stressors) and research-oriented diagnostic criteria that would attempt to facilitate reliable diagnoses based on common clusters of symptoms. Field trials sponsored by the National Institute of Mental Health began in 1977 to establish the reliability of the new diagnoses.
The year 1977 saw the first Apple computer, the New York City blackout, the release of the first “Star Wars” movie, and also the start of a momentous decade in general and child psychiatry. The third edition of the DSM (DSM-III) was published in 1980, the beginning of a revolution in psychiatric diagnosis and treatments. It created reliable, reproducible diagnostic constructs to serve as the basis for studies on epidemiology and treatment. Implications of causality were replaced by description; for example, hyperkinetic reaction of childhood was redefined and labeled attention-deficit disorder. Recognizing the importance of research and training in this rapidly changing field, W.T. Grant Foundation funded 11 fellowship programs in 1977, and the Society for Developmental and Behavioral Pediatrics was founded in 1982 by the leaders of those programs.
In 1983, The AACAP published “Child Psychiatry: A Plan for the Coming Decades.” It was the result of 5 years’ work by 100 child psychiatrists, general psychiatrists, pediatricians, epidemiologists, nurses, leaders of the NIMH, and various child advocates. This report laid out a challenge for child psychiatry to develop research strategies that would allow evidence-based understanding and treatment of the mental illnesses of children. The established focus on individual experience and anecdotal data, particularly about social and psychodynamic influences, would shift towards a more scientific approach to diagnosis and treatment. This decade started an explosion in epidemiologic research, medication trials, and controlled studies of nonbiological treatments in child psychiatry. At the same time, the political landscape changed, and an ascendant conservatism began the process of closing publicly funded residential treatment centers that had offered care to the more chronically mentally ill and children with profound developmental disorders. This would accelerate the shift towards outpatient psychiatric care of children. Ironically, as research would accelerate in child psychiatry, access to effective treatments would become more difficult.
The decade from 1987 to 1997 was a period of dramatic growth in medication use in child psychiatry. Prozac was approved by the Food and Drug Administration for use in the United States in 1988 and soon followed by other selective serotonin reuptake inhibitors (Zoloft in 1991 and Paxil in 1992). The journal of the AACAP began to publish more randomized controlled trials of medication treatments in children with DSM-codified diagnoses, and clinicians became more comfortable using stimulants, antidepressants, and even antipsychotic medications in the outpatient setting. This trend was enhanced by the emergence of managed care and the denial of coverage for alleged “nonbiological” diagnoses and for many psychiatric treatments. Loss of reimbursement led to a significant decline in resources, particularly inpatient child psychiatry beds and specialized clinics. This, in turn, contributed to the growing emphasis on medication treatments for children’s mental health problems. For-profit managed care companies underbid each other to provide mental health coverage and incentivized medication visits. Of note, the medical budgets, not the mental health carve outs, were billed for the medication prescribed.
The Americans with Disabilities Act was passed in 1990, increasing the funding for school-based mental health resources for children, and in 1996, Congress passed the Mental Health Parity Act, the first of several legislative attempts to ensure parity between insurance coverage for medical and psychiatric illnesses – legislation that to this day has not achieved parity of access to care. As pediatricians took on more of mental health care, a multidisciplinary team created a primary care version of DSM IV, the DSM-IV-PC, in 1995, to assist with defining levels of symptoms less than disorder to facilitate earlier intervention. A formal subspecialty of developmental-behavioral pediatrics was established in 1999 to educate leaders. Pediatric residents have had required training in developmental-behavioral pediatrics since 2008.
The year 1997 saw the first nationwide survey of parents about attention-deficit/hyperactivity disorder, kicking off what could be called the decade of ADHD, in which prevalence rates steadily climbed, from 5.7% in 1997 to 9.5% in 2007. The prevalence of stimulant treatment in children skyrocketed in this period. According to the NIMH, stimulants were prescribed to 4.2% of 6- to 12-year-olds in 1996, and that number grew to 5.1% in 2008. For 13- to 18-year-olds, the rate more than doubled during this time, from 2.3% in 1996 to 4.9% in 2008. The prevalence of autism also grew dramatically during this time, from 1.9 per 1,000 in 1997-1999 to 7.4 per 1,000 in 2006-2008, probably based on an evolving understanding of the disorder and this diagnosis providing special access to resources in schools.
Research during this decade became increasingly focused on imaging studies of children (and adults), as leaders in the field were trying to move from symptom clusters to anatomic and physiologic correlates of psychiatric illness. The great increase in medication use in children hit a speed bump in October 2004, when the Food and Drug Administration issued a controversial public warning about an increased risk of suicidal thoughts or behaviors in youth being treated with SSRI antidepressants. As access to child psychiatric treatment had become more difficult over the preceding decades, pediatricians had assumed much of the medication treatment of common psychiatric problems. The FDA’s black box warning complicated pediatricians’ efforts to fill this void.
The last decade has been the decade of genetics and efforts to improve access to care. It started in 2007 with the FDA expanding its SSRI warning to acknowledge that depression itself increased the risk for suicide, in an effort to not discourage needed depression treatment in young people. But studies demonstrated that the rates of diagnosing and treating depression dropped dramatically in the years following the warning: Diagnoses of depression declined by as much as 42% in children, and the rate of antidepressant treatment in adolescents dropped by as much as 32% in the 2 years following the warning (N Engl J Med. 2014 Oct 30;371(18):1666-8). There was no compensatory increase in utilization of other kinds of treatments. While suicide rates in young people had been stubbornly steady from the mid-1970’s to the mid-1990’s, they began to decline in 1996, according to the Centers for Disease Control and Prevention. But that trend was broken in 2004, with a jump in attempted and completed suicides in young people. The rate stabilized later in the decade, but has never returned to the lows that were being achieved prior to the warning.
This decade was marked by the passage of the Affordable Care Act, including – again – an unfulfilled mandate for mental health parity for any insurance plans in the marketplace. Although diagnosis is still symptom based, the effort to define psychiatric disorders based on brain anatomy, neurotransmitters, and genomics continues to intensify. There is growing evidence that psychiatric disorders are not nature or nurture, but nature and nurture. Epigenetic findings show that environment impacts gene expression and brain functioning. These findings promise to deepen our understanding of the critical role of early experiences (consider Adverse Childhood Experiences [ACE] scores) and the promise of protective relationships, in schools and parenting.
And what will come next? We believe that silos – medical, psychiatric, parenting, school, environment – will be bridged to understand the many factors that impact behavior and treatment, but the need to advocate for policies that support funding for the education and mental health care of children and the training of professionals to provide that care is never ending. As our knowledge of the genome marches forward, we may discover effective strategies for preventing the emergence of mental illness in children or create individualized treatments. We may learn more about the role of nutrition and the microbiome in health and disease, about autoimmunity and mental illness. Our focus may return to parents, not as culprits, but as the mediators of health from the prenatal period on. Technology may enable us to improve access to effective treatments, with teens monitoring their sleep and mood, and accessing therapy on their smart phones. And our understanding of development and vulnerability may help us stem the rise in autism or collaborate with educators so that education could better put every child on their healthiest possible path. We look forward to experiencing it – and writing about it – with you!
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. They said they had no relevant financial disclosures. Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email them at pdnews@frontlinemedcom.com.
The 50th anniversary of Pediatric News prompts us to look back on the past 50 years in child psychiatry and developmental-behavioral pediatrics, and reflect on the evolution of the field. This includes the approach to diagnosis, the thinking about development and family, and the approach and access to treatment during this dynamic period.
While some historians identify the establishment of the first juvenile court in Chicago in 1899 and the work to help judges evaluate juvenile delinquency as the origin of child psychiatry in the United States, it was not until after World War II that the field really began to take root here, largely based on psychiatrists fleeing Europe and the seminal work of Anna Freud. Some of the earliest connections between pediatrics and child psychiatry were based on the work in England of Donald W. Winnicott, a practicing pediatrician and child psychiatrist, Albert J. Solnit, MD, at the Yale Child Study Center, and psychologically informed work of pediatrician Benjamin M. Spock, MD.
The first Diagnostic and Statistical Manual (DSM) was published in 1952, based on a codification of mental disorders established by the Navy during WWII. The American Academy of Child & Adolescent Psychiatry was established in 1953, the same year that the first “tranquilizer,” chlorpromazine (Thorazine) was introduced (in France), marking the start of a revolution in psychiatric care. In 1959, the first candidates sat for a licensing examination in child psychiatry. The Section on Developmental and Behavioral Pediatrics was established as part of the American Academy of Pediatrics in 1960 to support training in this area. The AACAP established a journal in 1961. Child guidance clinics started affiliating with hospitals and universities in the 1960’s, after the Community Mental Health Act of 1963. Then, in 1965, Julius B. Richmond, MD, (a pediatrician) and Uri Bronfenbrenner, PhD, (a developmental psychologist), recognizing the importance of ecological systems to child development, were involved in the creation of Head Start, and the first Joint Commission on Mental Health for Children was established by federal legislation in 1965. The field was truly coalescing into a distinct discipline of medicine, one that bridged pediatrics, psychiatry, and neurology with nonmedical disciplines such as justice and education.
The decade between 1967 and 1977 was a period of transition from the focus on psychoanalytic concepts typical of the first half of the century to a more systematic approach to diagnosis. Children in psychiatric treatment had commonly been seen for extended individual treatments, and those with more disruptive disorders often were hospitalized for long periods. Psychoanalysis focused on the unconscious (theoretical drives and conflicts) to guide treatment. Treatment often focused on the role (causal) of parents, and family treatment was common, even on inpatient units. The second edition of the DSM (DSM-II) was published in 1968, with its first distinct section for disorders of childhood and adolescence, and an overarching focus on psychodynamics. In 1974, the decision was made to publish a new edition of the DSM that would establish a multiaxial assessment system (separating “biological” mental health problems from personality disorders, medical illnesses, and psychosocial stressors) and research-oriented diagnostic criteria that would attempt to facilitate reliable diagnoses based on common clusters of symptoms. Field trials sponsored by the National Institute of Mental Health began in 1977 to establish the reliability of the new diagnoses.
The year 1977 saw the first Apple computer, the New York City blackout, the release of the first “Star Wars” movie, and also the start of a momentous decade in general and child psychiatry. The third edition of the DSM (DSM-III) was published in 1980, the beginning of a revolution in psychiatric diagnosis and treatments. It created reliable, reproducible diagnostic constructs to serve as the basis for studies on epidemiology and treatment. Implications of causality were replaced by description; for example, hyperkinetic reaction of childhood was redefined and labeled attention-deficit disorder. Recognizing the importance of research and training in this rapidly changing field, W.T. Grant Foundation funded 11 fellowship programs in 1977, and the Society for Developmental and Behavioral Pediatrics was founded in 1982 by the leaders of those programs.
In 1983, The AACAP published “Child Psychiatry: A Plan for the Coming Decades.” It was the result of 5 years’ work by 100 child psychiatrists, general psychiatrists, pediatricians, epidemiologists, nurses, leaders of the NIMH, and various child advocates. This report laid out a challenge for child psychiatry to develop research strategies that would allow evidence-based understanding and treatment of the mental illnesses of children. The established focus on individual experience and anecdotal data, particularly about social and psychodynamic influences, would shift towards a more scientific approach to diagnosis and treatment. This decade started an explosion in epidemiologic research, medication trials, and controlled studies of nonbiological treatments in child psychiatry. At the same time, the political landscape changed, and an ascendant conservatism began the process of closing publicly funded residential treatment centers that had offered care to the more chronically mentally ill and children with profound developmental disorders. This would accelerate the shift towards outpatient psychiatric care of children. Ironically, as research would accelerate in child psychiatry, access to effective treatments would become more difficult.
The decade from 1987 to 1997 was a period of dramatic growth in medication use in child psychiatry. Prozac was approved by the Food and Drug Administration for use in the United States in 1988 and soon followed by other selective serotonin reuptake inhibitors (Zoloft in 1991 and Paxil in 1992). The journal of the AACAP began to publish more randomized controlled trials of medication treatments in children with DSM-codified diagnoses, and clinicians became more comfortable using stimulants, antidepressants, and even antipsychotic medications in the outpatient setting. This trend was enhanced by the emergence of managed care and the denial of coverage for alleged “nonbiological” diagnoses and for many psychiatric treatments. Loss of reimbursement led to a significant decline in resources, particularly inpatient child psychiatry beds and specialized clinics. This, in turn, contributed to the growing emphasis on medication treatments for children’s mental health problems. For-profit managed care companies underbid each other to provide mental health coverage and incentivized medication visits. Of note, the medical budgets, not the mental health carve outs, were billed for the medication prescribed.
The Americans with Disabilities Act was passed in 1990, increasing the funding for school-based mental health resources for children, and in 1996, Congress passed the Mental Health Parity Act, the first of several legislative attempts to ensure parity between insurance coverage for medical and psychiatric illnesses – legislation that to this day has not achieved parity of access to care. As pediatricians took on more of mental health care, a multidisciplinary team created a primary care version of DSM IV, the DSM-IV-PC, in 1995, to assist with defining levels of symptoms less than disorder to facilitate earlier intervention. A formal subspecialty of developmental-behavioral pediatrics was established in 1999 to educate leaders. Pediatric residents have had required training in developmental-behavioral pediatrics since 2008.
The year 1997 saw the first nationwide survey of parents about attention-deficit/hyperactivity disorder, kicking off what could be called the decade of ADHD, in which prevalence rates steadily climbed, from 5.7% in 1997 to 9.5% in 2007. The prevalence of stimulant treatment in children skyrocketed in this period. According to the NIMH, stimulants were prescribed to 4.2% of 6- to 12-year-olds in 1996, and that number grew to 5.1% in 2008. For 13- to 18-year-olds, the rate more than doubled during this time, from 2.3% in 1996 to 4.9% in 2008. The prevalence of autism also grew dramatically during this time, from 1.9 per 1,000 in 1997-1999 to 7.4 per 1,000 in 2006-2008, probably based on an evolving understanding of the disorder and this diagnosis providing special access to resources in schools.
Research during this decade became increasingly focused on imaging studies of children (and adults), as leaders in the field were trying to move from symptom clusters to anatomic and physiologic correlates of psychiatric illness. The great increase in medication use in children hit a speed bump in October 2004, when the Food and Drug Administration issued a controversial public warning about an increased risk of suicidal thoughts or behaviors in youth being treated with SSRI antidepressants. As access to child psychiatric treatment had become more difficult over the preceding decades, pediatricians had assumed much of the medication treatment of common psychiatric problems. The FDA’s black box warning complicated pediatricians’ efforts to fill this void.
The last decade has been the decade of genetics and efforts to improve access to care. It started in 2007 with the FDA expanding its SSRI warning to acknowledge that depression itself increased the risk for suicide, in an effort to not discourage needed depression treatment in young people. But studies demonstrated that the rates of diagnosing and treating depression dropped dramatically in the years following the warning: Diagnoses of depression declined by as much as 42% in children, and the rate of antidepressant treatment in adolescents dropped by as much as 32% in the 2 years following the warning (N Engl J Med. 2014 Oct 30;371(18):1666-8). There was no compensatory increase in utilization of other kinds of treatments. While suicide rates in young people had been stubbornly steady from the mid-1970’s to the mid-1990’s, they began to decline in 1996, according to the Centers for Disease Control and Prevention. But that trend was broken in 2004, with a jump in attempted and completed suicides in young people. The rate stabilized later in the decade, but has never returned to the lows that were being achieved prior to the warning.
This decade was marked by the passage of the Affordable Care Act, including – again – an unfulfilled mandate for mental health parity for any insurance plans in the marketplace. Although diagnosis is still symptom based, the effort to define psychiatric disorders based on brain anatomy, neurotransmitters, and genomics continues to intensify. There is growing evidence that psychiatric disorders are not nature or nurture, but nature and nurture. Epigenetic findings show that environment impacts gene expression and brain functioning. These findings promise to deepen our understanding of the critical role of early experiences (consider Adverse Childhood Experiences [ACE] scores) and the promise of protective relationships, in schools and parenting.
And what will come next? We believe that silos – medical, psychiatric, parenting, school, environment – will be bridged to understand the many factors that impact behavior and treatment, but the need to advocate for policies that support funding for the education and mental health care of children and the training of professionals to provide that care is never ending. As our knowledge of the genome marches forward, we may discover effective strategies for preventing the emergence of mental illness in children or create individualized treatments. We may learn more about the role of nutrition and the microbiome in health and disease, about autoimmunity and mental illness. Our focus may return to parents, not as culprits, but as the mediators of health from the prenatal period on. Technology may enable us to improve access to effective treatments, with teens monitoring their sleep and mood, and accessing therapy on their smart phones. And our understanding of development and vulnerability may help us stem the rise in autism or collaborate with educators so that education could better put every child on their healthiest possible path. We look forward to experiencing it – and writing about it – with you!
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. They said they had no relevant financial disclosures. Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email them at pdnews@frontlinemedcom.com.
Not enough time? Time to rethink
Raising children is a lot like drinking out of a fire hose. Feeding, cleaning, dressing, transporting, teaching, entertaining, protecting, comforting, and managing one child is demanding, but is increased exponentially by multiple children, a spouse, and a job.
In our dataset of more than 74,900 parents of 0- to 3-year-olds completing a routine previsit questionnaire about the “best” and “hardest” parts of parenting their child, the most frequent spontaneous comment for the hardest part was “time-life balance.” The goal of asking these questions is to broaden the agenda for the pediatric visit to address stresses that are highly relevant to the child’s life in the family, and their current well-being and future outcome. The hardest part also rather succinctly captures the stress I hear every day from parents coming to me not only for health supervision, but especially for child behavior problems.
Setting limits on work to free up more time is not possible for everyone. Many people are grateful to have a job at all or need multiple jobs to make ends meet. They may not be in a position to negotiate for fewer tasks, hours, or roles. But others more fortunate may have fallen into a habit of taking on extra duties, taking work home, or simply not examining where they might set limits to preserve time for themselves and their family.
Working parents may need to prepare themselves for the onslaught when they get home. If the returning parent retreats into TV, the computer, or the bedroom, it makes the children feel angry and rejected. The parent who has been managing the household for the preceding hour(s) feels resentful, unappreciated, and often exhausted. I sometimes suggest that the returning parent pause 15 minutes to take a walk before picking children up at day care or go to the gym before coming home to be ready to engage, accept, and be present for whatever happens when they open the door.
Eliciting the “hardest part” can insert a pause for some much-needed problem-solving. Pointing out to parents the value to their child of working on their own time-life balance often gives them needed permission to make changes.
Balancing time for some parents may include setting some privacy for “alone time.” Individual desire to be alone varies, but trouble getting it is universal, especially with young children who don’t even respect a closed bathroom door! Given a young child’s need for contact about every 3-5 minutes, parents need to revise their expectations, wait until after bedtime, get some help, learn to do “token” relaxation, or all of these.
Parents often feel guilty for not attending more to their child, but then feel irritable about getting behind on other chores. It can be useful to cite the fact that mothers at home full time typically spend only 20 minutes of exclusive playtime with their child. I regularly prescribe 15 minutes of “special time” daily to break this irritability cycle for both the parent and child. Getting a babysitter does not mean that the parent has to leave the house and the undone laundry. I often suggest to resource-strapped families that they pay an 8-year-old neighbor to play with their kids for an hour several times per week. While not expecting to leave the child alone with such a “sitter,” one could relax in the tub, read a magazine, or make an uninterrupted phone call to a friend with such help.
The same parents feeling the pinch of too little time often are lacking in social support, a major buffer of stress. Sometimes, the solutions overlap. For example, trading play dates with another family by taking all their kids on a regular basis and vice versa requires no money exchange. Several kids playing together are often easier to care for than one’s own with their usual sibling struggles or boredom. And sharing of this kind can build lasting friendships and social support for the adults. Another often forgotten source of adult rest coupled with social support is religious services that offer “Sunday School.” The service has built-in cues to meditation, the kids make new friends protected by accepting teachers, and the social hour builds social support for the parents.
But we can’t really insert more hours in the day, right? Actually, one of the most valuable suggestions may be for parents to keep a diary of their activities for a few days. The average American in 2015 clocked 147 minutes watching TV, 103 minutes in front of a computer, 151 minutes on smart phones, and 43 minutes with a tablet. These time wasters may not only not feel satisfying or even relaxing, but even prompt anxiety or envy, and certainly take away from sleep, exercise, and intimacy. The American Academy of Pediatrics recently provided a Media Calculator and Family Media Plan intended to help families consider these choices for their child’s media life within all the other required activities of a day (including sleep), but adults could benefit from the same approach to making decisions about how they budget their time.
By mapping out actual time spent, parents can then reevaluate and choose differently. A useful question we might ask frazzled parents is “What fills your tank?” to help them come up with a list of activities that (used to be) regenerative to put on the new schedule. Most people blurt out “go on a cruise” (not practical) when “token” activities can suffice and be immediately possible. Coach them to be creative! Instead of a cruise, take a walk around the block; instead of going to a spa, request a back rub at bedtime; instead of a movie, watch a YouTube clip. When allowing oneself to be fully present to such “tokens,” they can have immense value. The practice of mindfulness (for which many training apps are available) can heighten awareness of each moment and expand the sense of time. Meditation and yoga training both are proven to provide benefits for relaxation and well-being that can be fit into anyone’s day.
While this column is intended to help with pediatric practice, I’ll bet you thought I was talking about you! With the pace of current health care practice and emphasis on “productivity,” many pediatricians are struggling with balancing time for themselves and their families as well. All the ideas just discussed also apply to you, but maybe, just maybe, you have the resources to insist on limits on work you haven’t seized. Cherishing the years when you have children in your life is for you, too, not just your patients. Remember, “The days are long, but the years are short.”
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at pdnews@frontlinemedcom.com.
Raising children is a lot like drinking out of a fire hose. Feeding, cleaning, dressing, transporting, teaching, entertaining, protecting, comforting, and managing one child is demanding, but is increased exponentially by multiple children, a spouse, and a job.
In our dataset of more than 74,900 parents of 0- to 3-year-olds completing a routine previsit questionnaire about the “best” and “hardest” parts of parenting their child, the most frequent spontaneous comment for the hardest part was “time-life balance.” The goal of asking these questions is to broaden the agenda for the pediatric visit to address stresses that are highly relevant to the child’s life in the family, and their current well-being and future outcome. The hardest part also rather succinctly captures the stress I hear every day from parents coming to me not only for health supervision, but especially for child behavior problems.
Setting limits on work to free up more time is not possible for everyone. Many people are grateful to have a job at all or need multiple jobs to make ends meet. They may not be in a position to negotiate for fewer tasks, hours, or roles. But others more fortunate may have fallen into a habit of taking on extra duties, taking work home, or simply not examining where they might set limits to preserve time for themselves and their family.
Working parents may need to prepare themselves for the onslaught when they get home. If the returning parent retreats into TV, the computer, or the bedroom, it makes the children feel angry and rejected. The parent who has been managing the household for the preceding hour(s) feels resentful, unappreciated, and often exhausted. I sometimes suggest that the returning parent pause 15 minutes to take a walk before picking children up at day care or go to the gym before coming home to be ready to engage, accept, and be present for whatever happens when they open the door.
Eliciting the “hardest part” can insert a pause for some much-needed problem-solving. Pointing out to parents the value to their child of working on their own time-life balance often gives them needed permission to make changes.
Balancing time for some parents may include setting some privacy for “alone time.” Individual desire to be alone varies, but trouble getting it is universal, especially with young children who don’t even respect a closed bathroom door! Given a young child’s need for contact about every 3-5 minutes, parents need to revise their expectations, wait until after bedtime, get some help, learn to do “token” relaxation, or all of these.
Parents often feel guilty for not attending more to their child, but then feel irritable about getting behind on other chores. It can be useful to cite the fact that mothers at home full time typically spend only 20 minutes of exclusive playtime with their child. I regularly prescribe 15 minutes of “special time” daily to break this irritability cycle for both the parent and child. Getting a babysitter does not mean that the parent has to leave the house and the undone laundry. I often suggest to resource-strapped families that they pay an 8-year-old neighbor to play with their kids for an hour several times per week. While not expecting to leave the child alone with such a “sitter,” one could relax in the tub, read a magazine, or make an uninterrupted phone call to a friend with such help.
The same parents feeling the pinch of too little time often are lacking in social support, a major buffer of stress. Sometimes, the solutions overlap. For example, trading play dates with another family by taking all their kids on a regular basis and vice versa requires no money exchange. Several kids playing together are often easier to care for than one’s own with their usual sibling struggles or boredom. And sharing of this kind can build lasting friendships and social support for the adults. Another often forgotten source of adult rest coupled with social support is religious services that offer “Sunday School.” The service has built-in cues to meditation, the kids make new friends protected by accepting teachers, and the social hour builds social support for the parents.
But we can’t really insert more hours in the day, right? Actually, one of the most valuable suggestions may be for parents to keep a diary of their activities for a few days. The average American in 2015 clocked 147 minutes watching TV, 103 minutes in front of a computer, 151 minutes on smart phones, and 43 minutes with a tablet. These time wasters may not only not feel satisfying or even relaxing, but even prompt anxiety or envy, and certainly take away from sleep, exercise, and intimacy. The American Academy of Pediatrics recently provided a Media Calculator and Family Media Plan intended to help families consider these choices for their child’s media life within all the other required activities of a day (including sleep), but adults could benefit from the same approach to making decisions about how they budget their time.
By mapping out actual time spent, parents can then reevaluate and choose differently. A useful question we might ask frazzled parents is “What fills your tank?” to help them come up with a list of activities that (used to be) regenerative to put on the new schedule. Most people blurt out “go on a cruise” (not practical) when “token” activities can suffice and be immediately possible. Coach them to be creative! Instead of a cruise, take a walk around the block; instead of going to a spa, request a back rub at bedtime; instead of a movie, watch a YouTube clip. When allowing oneself to be fully present to such “tokens,” they can have immense value. The practice of mindfulness (for which many training apps are available) can heighten awareness of each moment and expand the sense of time. Meditation and yoga training both are proven to provide benefits for relaxation and well-being that can be fit into anyone’s day.
While this column is intended to help with pediatric practice, I’ll bet you thought I was talking about you! With the pace of current health care practice and emphasis on “productivity,” many pediatricians are struggling with balancing time for themselves and their families as well. All the ideas just discussed also apply to you, but maybe, just maybe, you have the resources to insist on limits on work you haven’t seized. Cherishing the years when you have children in your life is for you, too, not just your patients. Remember, “The days are long, but the years are short.”
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at pdnews@frontlinemedcom.com.
Raising children is a lot like drinking out of a fire hose. Feeding, cleaning, dressing, transporting, teaching, entertaining, protecting, comforting, and managing one child is demanding, but is increased exponentially by multiple children, a spouse, and a job.
In our dataset of more than 74,900 parents of 0- to 3-year-olds completing a routine previsit questionnaire about the “best” and “hardest” parts of parenting their child, the most frequent spontaneous comment for the hardest part was “time-life balance.” The goal of asking these questions is to broaden the agenda for the pediatric visit to address stresses that are highly relevant to the child’s life in the family, and their current well-being and future outcome. The hardest part also rather succinctly captures the stress I hear every day from parents coming to me not only for health supervision, but especially for child behavior problems.
Setting limits on work to free up more time is not possible for everyone. Many people are grateful to have a job at all or need multiple jobs to make ends meet. They may not be in a position to negotiate for fewer tasks, hours, or roles. But others more fortunate may have fallen into a habit of taking on extra duties, taking work home, or simply not examining where they might set limits to preserve time for themselves and their family.
Working parents may need to prepare themselves for the onslaught when they get home. If the returning parent retreats into TV, the computer, or the bedroom, it makes the children feel angry and rejected. The parent who has been managing the household for the preceding hour(s) feels resentful, unappreciated, and often exhausted. I sometimes suggest that the returning parent pause 15 minutes to take a walk before picking children up at day care or go to the gym before coming home to be ready to engage, accept, and be present for whatever happens when they open the door.
Eliciting the “hardest part” can insert a pause for some much-needed problem-solving. Pointing out to parents the value to their child of working on their own time-life balance often gives them needed permission to make changes.
Balancing time for some parents may include setting some privacy for “alone time.” Individual desire to be alone varies, but trouble getting it is universal, especially with young children who don’t even respect a closed bathroom door! Given a young child’s need for contact about every 3-5 minutes, parents need to revise their expectations, wait until after bedtime, get some help, learn to do “token” relaxation, or all of these.
Parents often feel guilty for not attending more to their child, but then feel irritable about getting behind on other chores. It can be useful to cite the fact that mothers at home full time typically spend only 20 minutes of exclusive playtime with their child. I regularly prescribe 15 minutes of “special time” daily to break this irritability cycle for both the parent and child. Getting a babysitter does not mean that the parent has to leave the house and the undone laundry. I often suggest to resource-strapped families that they pay an 8-year-old neighbor to play with their kids for an hour several times per week. While not expecting to leave the child alone with such a “sitter,” one could relax in the tub, read a magazine, or make an uninterrupted phone call to a friend with such help.
The same parents feeling the pinch of too little time often are lacking in social support, a major buffer of stress. Sometimes, the solutions overlap. For example, trading play dates with another family by taking all their kids on a regular basis and vice versa requires no money exchange. Several kids playing together are often easier to care for than one’s own with their usual sibling struggles or boredom. And sharing of this kind can build lasting friendships and social support for the adults. Another often forgotten source of adult rest coupled with social support is religious services that offer “Sunday School.” The service has built-in cues to meditation, the kids make new friends protected by accepting teachers, and the social hour builds social support for the parents.
But we can’t really insert more hours in the day, right? Actually, one of the most valuable suggestions may be for parents to keep a diary of their activities for a few days. The average American in 2015 clocked 147 minutes watching TV, 103 minutes in front of a computer, 151 minutes on smart phones, and 43 minutes with a tablet. These time wasters may not only not feel satisfying or even relaxing, but even prompt anxiety or envy, and certainly take away from sleep, exercise, and intimacy. The American Academy of Pediatrics recently provided a Media Calculator and Family Media Plan intended to help families consider these choices for their child’s media life within all the other required activities of a day (including sleep), but adults could benefit from the same approach to making decisions about how they budget their time.
By mapping out actual time spent, parents can then reevaluate and choose differently. A useful question we might ask frazzled parents is “What fills your tank?” to help them come up with a list of activities that (used to be) regenerative to put on the new schedule. Most people blurt out “go on a cruise” (not practical) when “token” activities can suffice and be immediately possible. Coach them to be creative! Instead of a cruise, take a walk around the block; instead of going to a spa, request a back rub at bedtime; instead of a movie, watch a YouTube clip. When allowing oneself to be fully present to such “tokens,” they can have immense value. The practice of mindfulness (for which many training apps are available) can heighten awareness of each moment and expand the sense of time. Meditation and yoga training both are proven to provide benefits for relaxation and well-being that can be fit into anyone’s day.
While this column is intended to help with pediatric practice, I’ll bet you thought I was talking about you! With the pace of current health care practice and emphasis on “productivity,” many pediatricians are struggling with balancing time for themselves and their families as well. All the ideas just discussed also apply to you, but maybe, just maybe, you have the resources to insist on limits on work you haven’t seized. Cherishing the years when you have children in your life is for you, too, not just your patients. Remember, “The days are long, but the years are short.”
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at pdnews@frontlinemedcom.com.
Threats in school: Is there a role for you?
Do you remember that kid in your class threatening to beat up a peer (or maybe you) after school? Mean children are not unique to current times. But actual threat to life while in school is a more recent problem, mainly due to the availability of firearms in American homes. Although rates of victimization have actually dropped 86% from 1992 to 2014, stories about school shootings are instantly broadcast across the country, making everyone feel that it could happen to them. Such public awareness also models threatening violence as a potent attention getter.
Often the threatening child lacks not only the skills to manage the frustrating situation, but also the language ability to choose less incendiary words. Saying, “I don’t think the way you handled that was fair to me,” might always be difficult, but is certainly impossible under the high emotions of the moment. Instead, “I’m going to kill you” pops out of their mouths. As for asking for help, school-aged children can only apologize or confess to being unsure a limited number of times before their need to save face takes precedence. This is especially true if they are confronted and humiliated in front of their peers.
Children who have oppositional or aggressive behavior diagnoses are by definition already in a pattern of reacting with hostility when demands are placed on them. In some cases, these negative reactions successfully get their parent(s) to back off the demand, resulting in what is called the “coercive cycle of interaction,” a prodrome to conduct disorder. Then, when a teacher issues a command, their reflexive response is more likely to be a defiant or aggressive one.
When threatening behavior is met by the supervising adults with confrontation, things may further accelerate, again especially in front of peers before whom the student does not want to look weak. Instead, a methodical approach to threat assessment in schools has been shown to be more effective. The main features of effective threat assessment involve identifying student threats, determining their seriousness, and developing intervention plans that both protect potential victims and address the underlying problem or conflict that sparked the threat.
A model program, Virginia Model for Student Threat Assessment by Dewey G. Cornell, PhD, of the University of Virginia, has been shown to help sort out transient (70%) from substantive (30%) threats and resulted in fewer long-term suspensions or expulsions and no cases in which the threats were carried out. (Send a copy to your local school superintendent.) While children receiving special education made three times more threats and more severe threats, they did not require more suspensions. With this threat assessment program, the number of disciplinary office referrals for these students declined by about 55% for the rest of that school year. Students in schools using this method reported less bullying, a greater willingness to seek help for bullying and threats, and more positive perceptions of the school climate as having fairer discipline and less aggression. Resulting plans to help the students involved in threats included modifications to special education plans, academic and behavioral support services, and referrals to mental health services. All these interventions are intended to address gaps in skills. In addition, ways to give even struggling students a meaningful connection to their school – for example, through sports, art, music, clubs, or volunteering – are essential components of both prevention and management.
There are several ways you, as a pediatrician, may be involved in the issue of threats at school. If one of your patients has been accused of threatening behavior, your knowledge of the child and family puts you in the best position to sort out the seriousness of the threat and appropriate next steps. Recently, one of my patients with mild autism was suspended for threatening to “kill the teacher.” He had never been aggressive at home or at school. This 8-year-old usually has a one-on-one aide, but the aide had been pulled to help other students. After an unannounced fire drill, the child called the teacher “evil” and was given his “third strike” for behavior, resulting in him making this threat.
Threat assessment in schools needs to follow the method of functional behavioral assessment, which should actually be standard for all school behavior problems. The method should consider the A (antecedent), B (behavior), C (consequence), and G (gaps) of the behavior. The antecedent here included the “setting” event of the fire drill. The behavior (sometimes also the belief) was the child’s negative reaction to the teacher (who had failed to protect him from being frightened). The consequence was a punishment (third strike) that the child felt was unfair. The gaps in skills included the facts that this is an anxious child who depends on support and routine because of his autism and who is also hypersensitive to loud noise such as a fire drill. In this case, I was able to explain these things to the school, but, in any case, you can, and should, request that the school perform a functional behavioral assessment when dealing with threats.
When you have a child with learning or emotional problems under your care, you need to include asking if they feel safe at school and if anything scary or bad has happened to them there. The parents may need to be directed to meet with school personnel about threats or fears the child reports. School violence prevention programs often include education of the children to be alert for and report threatening peers. This gives students an active role, but also may cause increased anxiety. Parents may need your support in requesting exemption from the school’s “violence prevention training” for anxious children. Anxious parents also may need extra coaching to avoid exposing their children to discussions about school threats.
In caring for all school-aged children (girls are as likely to be involved in school violence as boys), I ask about whether their teachers are nice or mean. I also ask if they have been bullied at school or have bullied others. I also sometimes ask struggling children, “If you had the choice, would you rather go to school or stay home?” The normal, almost universal preference is to go to school. School is the child’s job and social home, and, even when the work is hard, the need for mastery drives children to keep trying. Children preferring to be home are likely in pain and deserve careful assessment of their skills, their emotions, and the school and family environments.
While the percentage of students who reported being afraid of attack or harm at school decreased from 12% in 1995 to 3% in 2013, twice as many African American and Hispanic students feared being attacked than white students. It is clear that feeling anxious interferes with learning. Actual past experience with violence further lowers the threshold for feeling upset. The risk to learning of being fearful at school for children in stressed neighborhoods is multiplied by violence they may experience around them at home, causing even greater impact. Even when actual violence is rare, the media have put all kids and parents on edge about whether they are safe at school. This is a tragedy for everyone involved.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
Do you remember that kid in your class threatening to beat up a peer (or maybe you) after school? Mean children are not unique to current times. But actual threat to life while in school is a more recent problem, mainly due to the availability of firearms in American homes. Although rates of victimization have actually dropped 86% from 1992 to 2014, stories about school shootings are instantly broadcast across the country, making everyone feel that it could happen to them. Such public awareness also models threatening violence as a potent attention getter.
Often the threatening child lacks not only the skills to manage the frustrating situation, but also the language ability to choose less incendiary words. Saying, “I don’t think the way you handled that was fair to me,” might always be difficult, but is certainly impossible under the high emotions of the moment. Instead, “I’m going to kill you” pops out of their mouths. As for asking for help, school-aged children can only apologize or confess to being unsure a limited number of times before their need to save face takes precedence. This is especially true if they are confronted and humiliated in front of their peers.
Children who have oppositional or aggressive behavior diagnoses are by definition already in a pattern of reacting with hostility when demands are placed on them. In some cases, these negative reactions successfully get their parent(s) to back off the demand, resulting in what is called the “coercive cycle of interaction,” a prodrome to conduct disorder. Then, when a teacher issues a command, their reflexive response is more likely to be a defiant or aggressive one.
When threatening behavior is met by the supervising adults with confrontation, things may further accelerate, again especially in front of peers before whom the student does not want to look weak. Instead, a methodical approach to threat assessment in schools has been shown to be more effective. The main features of effective threat assessment involve identifying student threats, determining their seriousness, and developing intervention plans that both protect potential victims and address the underlying problem or conflict that sparked the threat.
A model program, Virginia Model for Student Threat Assessment by Dewey G. Cornell, PhD, of the University of Virginia, has been shown to help sort out transient (70%) from substantive (30%) threats and resulted in fewer long-term suspensions or expulsions and no cases in which the threats were carried out. (Send a copy to your local school superintendent.) While children receiving special education made three times more threats and more severe threats, they did not require more suspensions. With this threat assessment program, the number of disciplinary office referrals for these students declined by about 55% for the rest of that school year. Students in schools using this method reported less bullying, a greater willingness to seek help for bullying and threats, and more positive perceptions of the school climate as having fairer discipline and less aggression. Resulting plans to help the students involved in threats included modifications to special education plans, academic and behavioral support services, and referrals to mental health services. All these interventions are intended to address gaps in skills. In addition, ways to give even struggling students a meaningful connection to their school – for example, through sports, art, music, clubs, or volunteering – are essential components of both prevention and management.
There are several ways you, as a pediatrician, may be involved in the issue of threats at school. If one of your patients has been accused of threatening behavior, your knowledge of the child and family puts you in the best position to sort out the seriousness of the threat and appropriate next steps. Recently, one of my patients with mild autism was suspended for threatening to “kill the teacher.” He had never been aggressive at home or at school. This 8-year-old usually has a one-on-one aide, but the aide had been pulled to help other students. After an unannounced fire drill, the child called the teacher “evil” and was given his “third strike” for behavior, resulting in him making this threat.
Threat assessment in schools needs to follow the method of functional behavioral assessment, which should actually be standard for all school behavior problems. The method should consider the A (antecedent), B (behavior), C (consequence), and G (gaps) of the behavior. The antecedent here included the “setting” event of the fire drill. The behavior (sometimes also the belief) was the child’s negative reaction to the teacher (who had failed to protect him from being frightened). The consequence was a punishment (third strike) that the child felt was unfair. The gaps in skills included the facts that this is an anxious child who depends on support and routine because of his autism and who is also hypersensitive to loud noise such as a fire drill. In this case, I was able to explain these things to the school, but, in any case, you can, and should, request that the school perform a functional behavioral assessment when dealing with threats.
When you have a child with learning or emotional problems under your care, you need to include asking if they feel safe at school and if anything scary or bad has happened to them there. The parents may need to be directed to meet with school personnel about threats or fears the child reports. School violence prevention programs often include education of the children to be alert for and report threatening peers. This gives students an active role, but also may cause increased anxiety. Parents may need your support in requesting exemption from the school’s “violence prevention training” for anxious children. Anxious parents also may need extra coaching to avoid exposing their children to discussions about school threats.
In caring for all school-aged children (girls are as likely to be involved in school violence as boys), I ask about whether their teachers are nice or mean. I also ask if they have been bullied at school or have bullied others. I also sometimes ask struggling children, “If you had the choice, would you rather go to school or stay home?” The normal, almost universal preference is to go to school. School is the child’s job and social home, and, even when the work is hard, the need for mastery drives children to keep trying. Children preferring to be home are likely in pain and deserve careful assessment of their skills, their emotions, and the school and family environments.
While the percentage of students who reported being afraid of attack or harm at school decreased from 12% in 1995 to 3% in 2013, twice as many African American and Hispanic students feared being attacked than white students. It is clear that feeling anxious interferes with learning. Actual past experience with violence further lowers the threshold for feeling upset. The risk to learning of being fearful at school for children in stressed neighborhoods is multiplied by violence they may experience around them at home, causing even greater impact. Even when actual violence is rare, the media have put all kids and parents on edge about whether they are safe at school. This is a tragedy for everyone involved.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
Do you remember that kid in your class threatening to beat up a peer (or maybe you) after school? Mean children are not unique to current times. But actual threat to life while in school is a more recent problem, mainly due to the availability of firearms in American homes. Although rates of victimization have actually dropped 86% from 1992 to 2014, stories about school shootings are instantly broadcast across the country, making everyone feel that it could happen to them. Such public awareness also models threatening violence as a potent attention getter.
Often the threatening child lacks not only the skills to manage the frustrating situation, but also the language ability to choose less incendiary words. Saying, “I don’t think the way you handled that was fair to me,” might always be difficult, but is certainly impossible under the high emotions of the moment. Instead, “I’m going to kill you” pops out of their mouths. As for asking for help, school-aged children can only apologize or confess to being unsure a limited number of times before their need to save face takes precedence. This is especially true if they are confronted and humiliated in front of their peers.
Children who have oppositional or aggressive behavior diagnoses are by definition already in a pattern of reacting with hostility when demands are placed on them. In some cases, these negative reactions successfully get their parent(s) to back off the demand, resulting in what is called the “coercive cycle of interaction,” a prodrome to conduct disorder. Then, when a teacher issues a command, their reflexive response is more likely to be a defiant or aggressive one.
When threatening behavior is met by the supervising adults with confrontation, things may further accelerate, again especially in front of peers before whom the student does not want to look weak. Instead, a methodical approach to threat assessment in schools has been shown to be more effective. The main features of effective threat assessment involve identifying student threats, determining their seriousness, and developing intervention plans that both protect potential victims and address the underlying problem or conflict that sparked the threat.
A model program, Virginia Model for Student Threat Assessment by Dewey G. Cornell, PhD, of the University of Virginia, has been shown to help sort out transient (70%) from substantive (30%) threats and resulted in fewer long-term suspensions or expulsions and no cases in which the threats were carried out. (Send a copy to your local school superintendent.) While children receiving special education made three times more threats and more severe threats, they did not require more suspensions. With this threat assessment program, the number of disciplinary office referrals for these students declined by about 55% for the rest of that school year. Students in schools using this method reported less bullying, a greater willingness to seek help for bullying and threats, and more positive perceptions of the school climate as having fairer discipline and less aggression. Resulting plans to help the students involved in threats included modifications to special education plans, academic and behavioral support services, and referrals to mental health services. All these interventions are intended to address gaps in skills. In addition, ways to give even struggling students a meaningful connection to their school – for example, through sports, art, music, clubs, or volunteering – are essential components of both prevention and management.
There are several ways you, as a pediatrician, may be involved in the issue of threats at school. If one of your patients has been accused of threatening behavior, your knowledge of the child and family puts you in the best position to sort out the seriousness of the threat and appropriate next steps. Recently, one of my patients with mild autism was suspended for threatening to “kill the teacher.” He had never been aggressive at home or at school. This 8-year-old usually has a one-on-one aide, but the aide had been pulled to help other students. After an unannounced fire drill, the child called the teacher “evil” and was given his “third strike” for behavior, resulting in him making this threat.
Threat assessment in schools needs to follow the method of functional behavioral assessment, which should actually be standard for all school behavior problems. The method should consider the A (antecedent), B (behavior), C (consequence), and G (gaps) of the behavior. The antecedent here included the “setting” event of the fire drill. The behavior (sometimes also the belief) was the child’s negative reaction to the teacher (who had failed to protect him from being frightened). The consequence was a punishment (third strike) that the child felt was unfair. The gaps in skills included the facts that this is an anxious child who depends on support and routine because of his autism and who is also hypersensitive to loud noise such as a fire drill. In this case, I was able to explain these things to the school, but, in any case, you can, and should, request that the school perform a functional behavioral assessment when dealing with threats.
When you have a child with learning or emotional problems under your care, you need to include asking if they feel safe at school and if anything scary or bad has happened to them there. The parents may need to be directed to meet with school personnel about threats or fears the child reports. School violence prevention programs often include education of the children to be alert for and report threatening peers. This gives students an active role, but also may cause increased anxiety. Parents may need your support in requesting exemption from the school’s “violence prevention training” for anxious children. Anxious parents also may need extra coaching to avoid exposing their children to discussions about school threats.
In caring for all school-aged children (girls are as likely to be involved in school violence as boys), I ask about whether their teachers are nice or mean. I also ask if they have been bullied at school or have bullied others. I also sometimes ask struggling children, “If you had the choice, would you rather go to school or stay home?” The normal, almost universal preference is to go to school. School is the child’s job and social home, and, even when the work is hard, the need for mastery drives children to keep trying. Children preferring to be home are likely in pain and deserve careful assessment of their skills, their emotions, and the school and family environments.
While the percentage of students who reported being afraid of attack or harm at school decreased from 12% in 1995 to 3% in 2013, twice as many African American and Hispanic students feared being attacked than white students. It is clear that feeling anxious interferes with learning. Actual past experience with violence further lowers the threshold for feeling upset. The risk to learning of being fearful at school for children in stressed neighborhoods is multiplied by violence they may experience around them at home, causing even greater impact. Even when actual violence is rare, the media have put all kids and parents on edge about whether they are safe at school. This is a tragedy for everyone involved.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
Do as I say, not as I do! A futile plea
I am constantly amazed when parents come in complaining about their child’s nail biting or irritable attitude “no matter how many times I tell her” as they do these same things in front of me!
We have not evolved that far from our nonverbal ancestors to expect that words will speak louder than actions. Looking closely, you can see even very young infants gazing closely at their parents, then mirroring their facial expressions a few minutes later (because of slower processing). Mirroring is probably the correct word for this as the mirror neuron system of the brain has as its primary and crucial function allowing humans to copy what they see in others.
Children look to model, especially those who are slightly older and more adept than they are. Older siblings bask in this adoration at times and squeal in frustration at other times that their younger sister is “mocking” them by copying their speech and actions. When children are picking up serious negative behaviors from siblings or peers, particularly in adolescence, we need to coach parents to take action.
But watching parents is the most powerful or “salient” stimulus for learning. Some theorize that the long period of childhood evolved to allow children to learn the incredible amount of information necessary to live independently in our complex culture. This learning begins very early and requires close contact and careful observation of the minute details of how the parent survives every day.
Eating is a great primitive example of why children must model their parents. How do animals know which plants are poisonous? By watching others eat and spit, choke, or vomit. Entire families have nonpreferred foods passed on by modeling refusal as well as lack of exposure on the table. Conversely, picky eaters need to observe others, preferably admired peers and parents, eating those vegetables. (Tasting is also necessary, but that’s a topic for another day!) It is worth asking about family meals, without the distraction of a TV, as they are key moments to model nutritious eating for their lifetime.
In “underdeveloped” countries, infants are naturally carried everywhere and observing constantly. In our “developed” country, many infants spend hours each day at day care, modeling their caregivers or watching media examples of people interacting, which may not be the models parents would consciously choose. Parents often ask us about childcare, anxious about the extremely rare threat of abduction, when we should instead be advising them about what models they want for their children during this critical learning period.
Emotion cueing is a crucial component of modeling and an untaught constant of typical parent-child interaction. Crawling infants placed on a clear surface over a “visual cliff” that appeared to be a sudden precipice look to the parent’s affect to decide how to act. The mother was instructed to show fear or joy when her baby reached the apparent danger and looked up for a warning. When fear was shown, the infants backed off and cried. When joy was shown, the baby crawled gaily across the “cliff.” For parents who do not come by signaling confidence naturally but want to model this for their children, I advise they “fake it until you make it!”
Parents are instructing their progeny in how to feel and act in every situation, whether they know it or not. Confident parents model bravery; kind parents model compassion; flexible parents model resilience; patient parents model tolerance; anxious parents model caution; angry parents model aggression. Ignoring parents (think: on their cellphone, distracted, depressed, inebriated, or high) leave their children to feel confused and insecure. An adaptive child of an ignoring parent may demand information by crying, clinging, fighting with siblings, or hitting the parent. They are desperate for the parental attention to teach them and keep them safe. A more passive child may become increasingly inhibited in their exploration of the world. We need to consider possible modeling failures when such child reaction patterns are the complaint, and remember that the adverse model may not be in the room, requiring us to ask, “What other adult models does he see?”
Studies have shown that infants learn resilience when experiencing “mistakes” in parent-infant interaction; learning how to tolerate and repair an interaction that is not perfect. This is really good news for parents who feel that they must be perfect models for their children! For parents of anxious or obsessive children, I sometimes prescribe making mistakes and saying “Oh well,” as well as rewarding the child when they can say “Oh well” themselves. No child is too old to benefit from observing a parent apologize sincerely for a mistake.
Language is modeled, right down to accent. But when parents complain about their child cussing, raising their voice in anger, having an “attitude,” or “talking back,” it is worth asking (parent and child) “Where do you think they/you have heard talk like that?” It may be childcare providers, peers, TV, video games or online media (all of which may warrant a change), but it also may reflect interactions at home.
Children make stronger memories when emotions are high as these may signal danger, making recall more salient to survival. This salience helps explain the lasting detriments to learning and health of growing up with psychological abuse, marital discord, partner violence, mental illness, or criminal behavior (among the Adverse Childhood Experiences). Such experiences cause stress and a sense of the world as a dangerous place, but also become models for the child’s own later relationships as adults. While unavoidable, they can be buffered by parents’ explaining them and providing alternative positive modeling.
Watching the parent conduct their craft, a key component of apprenticeship and family businesses in the past, has been replaced by YouTube and avatars for learning physical skills. But “modeling the process” of pride in craftsmanship, persistence in a task, and recovering and starting over when things go awry are omitted from training videos. These are good reasons to assure that parents do chores, crafts, cooking, or camping with their children as some things will surely go wrong, giving parents the chance to model resilience and problem solving!
Although teens may protest conversations and activities, they are watching their parents for how to be a spouse, a neighbor, a friend, a leader, a citizen. Parents, who may be cutting their teens loose, need to continue to expect/require participation in family meals and outings. Those are opportunities to model adult-level interactions with each other and with the community as well as to talk about their activities at work, in volunteering, in charity, and in religious practice. The moral development of the adolescent is shaped by what they see to the degree that when parents state one moral code but violate it themselves (for example, cheating on taxes, running red lights), the teen is less likely to follow the principles long term that the parents have verbalized.
Parents often relate to us as though we were their own parents. While this “projection” can interfere with disclosure on touchy subjects, it is also an opportunity for us to model ways of relating and reacting from sympathizing with the 4-year-old screaming about vaccines to asking an 8-year-old why he thinks his parents are getting a divorce.
Parenting (and being a pediatrician) is an opportunity to enjoy reliving your youth or to get a “do over” of parts you would like to have different for your child. Playfulness and silliness model joy for the child that can last a lifetime.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at pdnews@frontlinemedcom.com.
I am constantly amazed when parents come in complaining about their child’s nail biting or irritable attitude “no matter how many times I tell her” as they do these same things in front of me!
We have not evolved that far from our nonverbal ancestors to expect that words will speak louder than actions. Looking closely, you can see even very young infants gazing closely at their parents, then mirroring their facial expressions a few minutes later (because of slower processing). Mirroring is probably the correct word for this as the mirror neuron system of the brain has as its primary and crucial function allowing humans to copy what they see in others.
Children look to model, especially those who are slightly older and more adept than they are. Older siblings bask in this adoration at times and squeal in frustration at other times that their younger sister is “mocking” them by copying their speech and actions. When children are picking up serious negative behaviors from siblings or peers, particularly in adolescence, we need to coach parents to take action.
But watching parents is the most powerful or “salient” stimulus for learning. Some theorize that the long period of childhood evolved to allow children to learn the incredible amount of information necessary to live independently in our complex culture. This learning begins very early and requires close contact and careful observation of the minute details of how the parent survives every day.
Eating is a great primitive example of why children must model their parents. How do animals know which plants are poisonous? By watching others eat and spit, choke, or vomit. Entire families have nonpreferred foods passed on by modeling refusal as well as lack of exposure on the table. Conversely, picky eaters need to observe others, preferably admired peers and parents, eating those vegetables. (Tasting is also necessary, but that’s a topic for another day!) It is worth asking about family meals, without the distraction of a TV, as they are key moments to model nutritious eating for their lifetime.
In “underdeveloped” countries, infants are naturally carried everywhere and observing constantly. In our “developed” country, many infants spend hours each day at day care, modeling their caregivers or watching media examples of people interacting, which may not be the models parents would consciously choose. Parents often ask us about childcare, anxious about the extremely rare threat of abduction, when we should instead be advising them about what models they want for their children during this critical learning period.
Emotion cueing is a crucial component of modeling and an untaught constant of typical parent-child interaction. Crawling infants placed on a clear surface over a “visual cliff” that appeared to be a sudden precipice look to the parent’s affect to decide how to act. The mother was instructed to show fear or joy when her baby reached the apparent danger and looked up for a warning. When fear was shown, the infants backed off and cried. When joy was shown, the baby crawled gaily across the “cliff.” For parents who do not come by signaling confidence naturally but want to model this for their children, I advise they “fake it until you make it!”
Parents are instructing their progeny in how to feel and act in every situation, whether they know it or not. Confident parents model bravery; kind parents model compassion; flexible parents model resilience; patient parents model tolerance; anxious parents model caution; angry parents model aggression. Ignoring parents (think: on their cellphone, distracted, depressed, inebriated, or high) leave their children to feel confused and insecure. An adaptive child of an ignoring parent may demand information by crying, clinging, fighting with siblings, or hitting the parent. They are desperate for the parental attention to teach them and keep them safe. A more passive child may become increasingly inhibited in their exploration of the world. We need to consider possible modeling failures when such child reaction patterns are the complaint, and remember that the adverse model may not be in the room, requiring us to ask, “What other adult models does he see?”
Studies have shown that infants learn resilience when experiencing “mistakes” in parent-infant interaction; learning how to tolerate and repair an interaction that is not perfect. This is really good news for parents who feel that they must be perfect models for their children! For parents of anxious or obsessive children, I sometimes prescribe making mistakes and saying “Oh well,” as well as rewarding the child when they can say “Oh well” themselves. No child is too old to benefit from observing a parent apologize sincerely for a mistake.
Language is modeled, right down to accent. But when parents complain about their child cussing, raising their voice in anger, having an “attitude,” or “talking back,” it is worth asking (parent and child) “Where do you think they/you have heard talk like that?” It may be childcare providers, peers, TV, video games or online media (all of which may warrant a change), but it also may reflect interactions at home.
Children make stronger memories when emotions are high as these may signal danger, making recall more salient to survival. This salience helps explain the lasting detriments to learning and health of growing up with psychological abuse, marital discord, partner violence, mental illness, or criminal behavior (among the Adverse Childhood Experiences). Such experiences cause stress and a sense of the world as a dangerous place, but also become models for the child’s own later relationships as adults. While unavoidable, they can be buffered by parents’ explaining them and providing alternative positive modeling.
Watching the parent conduct their craft, a key component of apprenticeship and family businesses in the past, has been replaced by YouTube and avatars for learning physical skills. But “modeling the process” of pride in craftsmanship, persistence in a task, and recovering and starting over when things go awry are omitted from training videos. These are good reasons to assure that parents do chores, crafts, cooking, or camping with their children as some things will surely go wrong, giving parents the chance to model resilience and problem solving!
Although teens may protest conversations and activities, they are watching their parents for how to be a spouse, a neighbor, a friend, a leader, a citizen. Parents, who may be cutting their teens loose, need to continue to expect/require participation in family meals and outings. Those are opportunities to model adult-level interactions with each other and with the community as well as to talk about their activities at work, in volunteering, in charity, and in religious practice. The moral development of the adolescent is shaped by what they see to the degree that when parents state one moral code but violate it themselves (for example, cheating on taxes, running red lights), the teen is less likely to follow the principles long term that the parents have verbalized.
Parents often relate to us as though we were their own parents. While this “projection” can interfere with disclosure on touchy subjects, it is also an opportunity for us to model ways of relating and reacting from sympathizing with the 4-year-old screaming about vaccines to asking an 8-year-old why he thinks his parents are getting a divorce.
Parenting (and being a pediatrician) is an opportunity to enjoy reliving your youth or to get a “do over” of parts you would like to have different for your child. Playfulness and silliness model joy for the child that can last a lifetime.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at pdnews@frontlinemedcom.com.
I am constantly amazed when parents come in complaining about their child’s nail biting or irritable attitude “no matter how many times I tell her” as they do these same things in front of me!
We have not evolved that far from our nonverbal ancestors to expect that words will speak louder than actions. Looking closely, you can see even very young infants gazing closely at their parents, then mirroring their facial expressions a few minutes later (because of slower processing). Mirroring is probably the correct word for this as the mirror neuron system of the brain has as its primary and crucial function allowing humans to copy what they see in others.
Children look to model, especially those who are slightly older and more adept than they are. Older siblings bask in this adoration at times and squeal in frustration at other times that their younger sister is “mocking” them by copying their speech and actions. When children are picking up serious negative behaviors from siblings or peers, particularly in adolescence, we need to coach parents to take action.
But watching parents is the most powerful or “salient” stimulus for learning. Some theorize that the long period of childhood evolved to allow children to learn the incredible amount of information necessary to live independently in our complex culture. This learning begins very early and requires close contact and careful observation of the minute details of how the parent survives every day.
Eating is a great primitive example of why children must model their parents. How do animals know which plants are poisonous? By watching others eat and spit, choke, or vomit. Entire families have nonpreferred foods passed on by modeling refusal as well as lack of exposure on the table. Conversely, picky eaters need to observe others, preferably admired peers and parents, eating those vegetables. (Tasting is also necessary, but that’s a topic for another day!) It is worth asking about family meals, without the distraction of a TV, as they are key moments to model nutritious eating for their lifetime.
In “underdeveloped” countries, infants are naturally carried everywhere and observing constantly. In our “developed” country, many infants spend hours each day at day care, modeling their caregivers or watching media examples of people interacting, which may not be the models parents would consciously choose. Parents often ask us about childcare, anxious about the extremely rare threat of abduction, when we should instead be advising them about what models they want for their children during this critical learning period.
Emotion cueing is a crucial component of modeling and an untaught constant of typical parent-child interaction. Crawling infants placed on a clear surface over a “visual cliff” that appeared to be a sudden precipice look to the parent’s affect to decide how to act. The mother was instructed to show fear or joy when her baby reached the apparent danger and looked up for a warning. When fear was shown, the infants backed off and cried. When joy was shown, the baby crawled gaily across the “cliff.” For parents who do not come by signaling confidence naturally but want to model this for their children, I advise they “fake it until you make it!”
Parents are instructing their progeny in how to feel and act in every situation, whether they know it or not. Confident parents model bravery; kind parents model compassion; flexible parents model resilience; patient parents model tolerance; anxious parents model caution; angry parents model aggression. Ignoring parents (think: on their cellphone, distracted, depressed, inebriated, or high) leave their children to feel confused and insecure. An adaptive child of an ignoring parent may demand information by crying, clinging, fighting with siblings, or hitting the parent. They are desperate for the parental attention to teach them and keep them safe. A more passive child may become increasingly inhibited in their exploration of the world. We need to consider possible modeling failures when such child reaction patterns are the complaint, and remember that the adverse model may not be in the room, requiring us to ask, “What other adult models does he see?”
Studies have shown that infants learn resilience when experiencing “mistakes” in parent-infant interaction; learning how to tolerate and repair an interaction that is not perfect. This is really good news for parents who feel that they must be perfect models for their children! For parents of anxious or obsessive children, I sometimes prescribe making mistakes and saying “Oh well,” as well as rewarding the child when they can say “Oh well” themselves. No child is too old to benefit from observing a parent apologize sincerely for a mistake.
Language is modeled, right down to accent. But when parents complain about their child cussing, raising their voice in anger, having an “attitude,” or “talking back,” it is worth asking (parent and child) “Where do you think they/you have heard talk like that?” It may be childcare providers, peers, TV, video games or online media (all of which may warrant a change), but it also may reflect interactions at home.
Children make stronger memories when emotions are high as these may signal danger, making recall more salient to survival. This salience helps explain the lasting detriments to learning and health of growing up with psychological abuse, marital discord, partner violence, mental illness, or criminal behavior (among the Adverse Childhood Experiences). Such experiences cause stress and a sense of the world as a dangerous place, but also become models for the child’s own later relationships as adults. While unavoidable, they can be buffered by parents’ explaining them and providing alternative positive modeling.
Watching the parent conduct their craft, a key component of apprenticeship and family businesses in the past, has been replaced by YouTube and avatars for learning physical skills. But “modeling the process” of pride in craftsmanship, persistence in a task, and recovering and starting over when things go awry are omitted from training videos. These are good reasons to assure that parents do chores, crafts, cooking, or camping with their children as some things will surely go wrong, giving parents the chance to model resilience and problem solving!
Although teens may protest conversations and activities, they are watching their parents for how to be a spouse, a neighbor, a friend, a leader, a citizen. Parents, who may be cutting their teens loose, need to continue to expect/require participation in family meals and outings. Those are opportunities to model adult-level interactions with each other and with the community as well as to talk about their activities at work, in volunteering, in charity, and in religious practice. The moral development of the adolescent is shaped by what they see to the degree that when parents state one moral code but violate it themselves (for example, cheating on taxes, running red lights), the teen is less likely to follow the principles long term that the parents have verbalized.
Parents often relate to us as though we were their own parents. While this “projection” can interfere with disclosure on touchy subjects, it is also an opportunity for us to model ways of relating and reacting from sympathizing with the 4-year-old screaming about vaccines to asking an 8-year-old why he thinks his parents are getting a divorce.
Parenting (and being a pediatrician) is an opportunity to enjoy reliving your youth or to get a “do over” of parts you would like to have different for your child. Playfulness and silliness model joy for the child that can last a lifetime.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at pdnews@frontlinemedcom.com.
